Article

Efficacy study of a vest‐type device for positional therapy in position dependent snorers

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Abstract

This study was performed to evaluate the efficacy of positional therapy using a recently developed vest-type device to treat snoring in positional-dependent snorers. Seventeen (60.7%) of the 28 subjects were diagnosed as position-dependent snorers with or without mild obstructive sleep apnea through laboratory nocturnal polysomnography and were included in a pre- and post-treatment comparative parallel study. The mean total snoring rate (from 36.7 ± 20.6% to 15.7 ± 16.2%, P < 0.0001) and snoring rate in the supine position (from 45.8 ± 22.8% to 25.4 ± 20.6%, P < 0.0001) decreased significantly with use of the vest. The mean percent change of total snoring rate between baseline and with the positional device was significant (63.5 ± 22.5%, P < 0.0001). Of the 17 subjects, 15 (88.2%) decreased their snoring rate more than 50% without subjective adverse effects. There were no significant differences in sleep efficiency, arousal index, and wake after sleep onset while sleeping with the vest-type positional device. In conclusion, positional therapy using the recently developed vest-type device is effective at decreasing snoring without subjective and objective adverse effects in position-dependent snorers with or without mild obstructive sleep apnea.

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... In the apneic group, the snoring time was 16.9% and 15.4% and the intensity 102.9 and 103.5 dB in the supine and non-supine positions, respectively. Choi et al. [40] defined a position-dependent snorer as " one who has a greater than 50% reduction of snoring rate in the lateral position compared to that in the supine position . " To our best knowledge, the prevalence of positiondependent snoring is yet to be reported. ...
... The worst sleeping position is usually , but not always, the supine position [35] . Various techniques are described to prevent patients from assuming the supine position such as positional alarms, verbal instructions , tennis balls (TBT), vests, " shark fins, " or special pillows [7, 27, 29,4041424344454647484950515253. The effect of positional therapy on snoring Rationale In 1948, Robin [17] stated that " many persons snore only when on their backs " and suggested that on some occasions, sewing a cotton reel into the back of a pyjama can be effective, albeit rather uncomfortable. ...
... The number of snores remained 356/hour both with and without PT. Choi et al. [40] evaluated the efficacy of PT (vest with two inflatable chambers) to treat snoring in 17 positionaldependent snorers, defined as one who has a >50% reduction of snoring rate in the lateral position compared with that in the supine position. The snoring rate decreased from 36.7% to 15.7% without subjective or objective adverse effects. ...
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Purpose Research during the past 10–20 years shows that positional therapy (PT) has a significant influence on the apnea–hypopnea index. These studies are predominantly performed as case series on a comparably small number of patients. Still, results have not found their way into the daily diagnostic and treatment routine. An average of 56 % of patients with obstructive sleep apnea (OSA) have position-dependent OSA (POSA), commonly defined as a difference of 50 % or more in apnea index between supine and non-supine positions. A great deal could be gained in treating patients with POSA with PT. The aim of this paper was to perform a thorough review of the literature on positional sleep apnea and its therapy. Methods A broad search strategy was run electronically in the MEDLINE and EMBASE databases using synonyms for position and sleep apnea. Results Sixteen studies were found which examined the effect of PT on OSA. In this literature review, we discuss the various techniques, results, and compliance rates. Conclusion Long-term compliance for PT remains an issue, and although remarkable results have been shown using innovative treatment concepts for PT, there is room for both technical improvement of the devices and for further research.
... Nakano et al. found that snoring time and snoring intensity were lower in the lateral position than in the supine position in non-apneic snorers [18]. Choi et al. described that in non-apneic snorers, snoring decreased when a subject adopted a non-supine position [19]. A retrospective study performed by Benoist et al. looked at position dependency in non-apneic snorers seeking clinical care and found that 65.8% of this group is position dependent [20]. ...
... These results are in line with the findings of our study where the VAS score also decreased with one point after therapy (from 8.0 to 7.0). Choi et al. studied the effect of PT using an inflatable vesttype device, in position-dependent snorers, with or without mild OSA [19]. A relevant effect was defined as a > 50% reduction of snoring rate in lateral position compared with the snoring rate in supine position. ...
Article
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Purpose: To evaluate the effect of a new-generation positional device, the sleep position trainer (SPT), in non-apneic position-dependent snorers. Methods: Non-apneic position-dependent snorers with an apnea-hypopnea index (AHI) < 5 events/h were included between February 2015 and September 2016. After inclusion, study subjects used the SPT at home for 6 weeks. The Snore Outcome Survey (SOS) was filled out by the subjects at baseline and after 6 weeks, and at the same time, the Spouse/Bed Partner Survey (SBPS) was filled out by their bed partners. Results: A total of 36 participants were included and 30 completed the study. SOS score improved significantly after 6 weeks from 35.0 ± 13.5 to 55.3 ± 18.6, p < 0.001. SBPS score also improved significantly after 6 weeks from 24.7 ± 16.0 versus 54.5 ± 25.2, p < 0.001. The severity of snoring assessed with a numeric visual analogue scale (VAS) by the bed partner decreased significantly from a median of 8.0 with an interquartile range (IQR) of [7.0-8.5] to 7.0 [3.8-8.0] after 6 weeks (p = 0.004). Conclusions: Results of this study indicate that positional therapy with the SPT improved several snoring-related outcome measures in non-apneic position-dependent snorers. The results of this non-controlled study demonstrate that this SPT could be considered as an alternative therapeutic option to improve sleep-related health status of snorers and their bed partners.
... Patients with POSA are estimated to comprise 70% to 80% of those with mild (AHI = 5-14 hr -1 ) and moderate OSA (AHI = 15-29 hr -1 ), and approximately 56% to 75% of patients with severe OSA (AHI ≥ 30 hr -1 ) [13][14][15]. In POSA, sleeping in the supine position is associated with worse OSA [16], and many forms of positional therapy have been developed in an attempt to improve long-term adherence, e.g., chest-worn sleep position trainers, tennis ball technique, positional alarms, and verbal instructions urging patients to shift to a non-supine body position when the supine body position is detected [17][18][19]. These treatments induce pain and discomfort, and subsequently disrupt the sleep architecture, which also limit compliance. ...
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Background and Objective Patients with position-dependent obstructive sleep apnea have a > 2-fold higher apnea-hypopnea index when sleeping in a supine position compared with a non-supine position. We investigated the effect of body pillow use on sleeping body position and sleep architecture in healthy young adults. Methods In experiment 1, we evaluated the body pressure distribution with or without body pillow use in 8 healthy young adults [age, 36.5 ± 13.0 years; body mass index (BMI); 20.6 ± 1.2 kg/m2]. In experiment 2, we performed a randomized-crossover intervention study to evaluate the effects of body pillow use on sleeping position and sleep architecture in 10 healthy young adults (age, 24.3 ± 7.8 years; BMI, 21.4 ± 1.7 kg/m2). Sleep architecture was characterized by polysomnography, and body positions were monitored using a sensor. Subjective sleep quality was evaluated with the Oguri-Shirakawa-Azumi sleep inventory, middle age and aged version. Results In experiment 1, body pillow use significantly reduced mean body pressure on the shoulder, hip, and whole body. In experiment 2, mean time spent in the supine, lateral, and prone body positions did not differ significantly between the 2 trials. Body pillow use, however, significantly extended the sustained time spent in the lateral body position compared with the control trial. Subjective sleep quality and sleep architecture did not differ significantly between the 2 trials, but body pillow use decreased the number of short (30 s) slow-wave sleep episodes. Conclusions Sleeping with a body pillow effectively extends sustained time in a lateral sleeping position and prevents segmentation of slow-wave sleep episodes. Key Words: Body pillow, Sleeping body position, Lateral position, Sleep architecture, Energy expenditure
... l The vest-type design [21]. This device is of a vest-type design with a connected controller. ...
Article
Positional therapy is the avoidance of the supine posture during sleep for patients with supine-related sleep apnea. This therapy is mainly suitable for patients with supine-related sleep apnea (positional patients) who have most of their breathing abnormalities concentrated in the supine posture, and in whom while sleeping in the lateral postures (and sometimes in the prone posture), the amount of breathing abnormalities is significantly reduced to a nonpathological level. If a sleep apnea patient has mainly apneas and hypopneas in the supine posture, but when sleeping in the lateral positions or prone posture these breathing abnormalities disappear or are markedly reduced to a non-pathological level, it is almost intuitively obvious that this patient should avoid the supine posture during sleep. It is not clear, however, how the patient should accomplish this task during sleep. To avoid this posture during sleep, and thereafter to learn how to sleep only in the other postures (mainly the lateral posture), it becomes important to find a simple behavioral therapy.
... This, however, is seen in the majority of the literature looking at position dependence in non-apneic patients. One study defined position-dependent snoring as a [50 % reduction in snoring rate in the lateral position when compared with the supine position [20]. There are, however, no standardized guidelines defining criteria for position-dependent snoring. ...
Article
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The aims of this study are to determine the prevalence of position dependency in non-apneic snorers, as defined by the American Academy of Sleep Medicine (AASM) guidelines, and to investigate the influence of various factors such as BMI, neck circumference, age, gender, and sleep efficiency on sleeping position. A cohort of consecutive patients was screened for complaints of excessive snoring or symptoms suspicious for sleep disordered breathing. Overnight polysomnographic data were collected and non-apneic snorers who met all the inclusion criteria were selected for statistical analysis. To assess position-dependent snoring, the snore index (total snores/h) was used. Supine-dependent patients were defined as having a supine snore index higher than their total non-supine snore index. 76 patients were eligible for statistical analysis. Prevalence of position dependency in non-apneic snorers was 65.8 % (p < 0.008). A stepwise regression showed that only BMI had a significant effect (p < 0.003) on the supine snore index. This is the first study that uses the AASM guidelines to accurately define non-apneic snorers (AHI < 5) and provides scientific evidence that the majority of non-apneic snorers are supine dependent. Furthermore, these results show that non-apneic snorers with a higher BMI snore more frequently in supine position. The use of sleep position therapy therefore, has the potential to play a significant role in improving snoring and its associated physical and psychosocial health outcomes in this population.
... Improvements in the bedding material to reduce the compression in this area could reduce the unpleasant effects of PPP. Many techniques are described previously to prevent patients from assuming the supine position such as positional alarms, verbal instructions, tennis balls, vests, "shark fins," or special pillows [38][39][40][41][42][43][44][45][46]. A recent review about positional therapy of OSA reported that since remarkable results have been shown using innovative treatment concepts for positional therapy, there is room for both technical improvement of the devices and for further research [47]. ...
Article
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Sleeping in prone position could be effective in the management of obstructive sleep apnea (OSA) syndrome by reducing the gravity effect on the upper airway and hence collapsibility. Effect of pure prone positioning (PPP) treatment was investigated in mild to moderate OSA. Twenty-nine mild to moderate OSA patients (17 males, 12 females) who gave informed consent were tested with polysomnography at diagnostic and PPP nights. PPP device consisted of a pillow mounted on a table with a hole in the middle keeping the neck 180° extended in prone position. Mean ± SD of age and AHI were 48.4 ± 10.6 and 15.5 ± 6.2, respectively. Patients did not have abdominal and/or truncalobesity, or any condition that could interfere with prone sleeping. AHI (mean difference: PPP treatment - diagnostic night: -5.2/h, 95 % confidence interval [CI]: -0.1/h to -10.3/h, p = 0.04) and sleep oxygen saturation below 90 % (mean difference: -1.80 %, 95 % CI: -0.22 % to -3.37 %, p = 0.02) and sleep efficiency (81.0 ± 21.2 % and 88.1 ± 7.1 %, respectively, p = 0.02) were significantly lower in PPP than diagnostic night. Response to PPP treatment defined as AHI <5/h in the PPP night was observed in 15 (51.7 %) patients, with a better rate in female than male patients (9/12 vs. 6/17, respectively, p = 0.03). To our knowledge, this is the first study to examine the effect of prone positioning in the treatment of mild to moderate OSA. Application of PPP with a more comfortable design in a randomized clinical trial is required to investigate its long term effect in the treatment of mild to moderate OSA.
... Tennis ball therapy has been described previously, and several kinds of pillows and bedding are available for patients [6]. Equipment has been developed to promote a lateral position automatically by using devices such as inflatable air chambers and motorized swings [7,8]. Recently, vibrotactile small position therapy devices (PTDs) have been developed and are becoming popular in Europe. ...
Article
Full-text available
PurposeThe purpose of this study was to elucidate the effect of a neck-worn position therapy device (PTD) and oral appliance (OA) on sleep parameters in patients with obstructive sleep apnea (OSA).Methods Patients with an apnea hypopnea index (AHI) of 5/h or more at baseline polysomnography were divided into a PTD group and an OA group randomly. All participants underwent a type 1 polysomnography for diagnosis and device-set outcome measurements.ResultsThe PTD decreased the AHI from a mean of 24.2/h to 16.7/h, and the OA decreased the AHI from 20.8/h to 10.3/h. Snoring duration decreased from 31.1% to 16.9% in the PTD group, and from 41.2% to 30.7% in the OA group. There were no significant differences in these decreases between the two groups. The PTD decreased sleep-time percentage in the supine position from a mean of 67.4% to 4.5%, despite five patients who were unable to avoid the supine position. There were no significant differences in improvement in sleep efficiency, percentage of stage wake, stage N1, stage N2, and stage REM, and overall arousal and respiratory arousal indices between the two groups. However, the spontaneous arousal index worsened in the OA responders but remained unchanged in the PTD responders. Percentage of stage N3 sleep (%N3) was improved in the PTD responders but not in the OA responders. There were significant differences in spontaneous arousal index and %N3 between the two groups.ConclusionPTDs are a potential treatment modality that does not disturb sleep in patients with OSA.
... Improvements in the bedding material to reduce the compression in this area could reduce the unpleasant effects of PPP. Many techniques are described previously to prevent patients from assuming the supine position such as positional alarms, verbal instructions, tennis balls, vests, "shark fins," or special pillows [38][39][40][41][42][43][44][45][46]. A recent review about positional therapy of OSA reported that since remarkable results have been shown using innovative treatment concepts for positional therapy, there is room for both technical improvement of the devices and for further research [47]. ...
Article
Full-text available
Background Sleeping in prone position could be effective in the management of obstructive sleep apnea (OSA) syndrome by reducing the gravity effect on the upper airway and hence collapsibility. Effect of pure prone positioning (PPP) treatment was investigated in mild to moderate OSA. Patients and methods Twenty-nine mild to moderate OSA patients (17 males, 12 females) who gave informed consent were tested with polysomnography at diagnostic and PPP nights. PPP device consisted of a pillow mounted on a table with a hole in the middle keeping the neck 180° extended in prone position. Mean±SD of age and AHI were 48.4±10.6 and 15.5±6.2, respectively. Patients did not have abdominal and/or truncalobesity, or any condition that could interfere with prone sleeping. Results AHI (mean difference: PPP treatment−diagnostic night: −5.2/h, 95 % confidence interval [CI]: −0.1/h to −10.3/h, p=0.04) and sleep oxygen saturation below 90 % (mean difference: −1.80 %, 95 % CI: −0.22 % to −3.37 %, p= 0.02) and sleep efficiency (81.0±21.2 % and 88.1±7.1 %, respectively, p=0.02) were significantly lower in PPP than diagnostic night. Response to PPP treatment defined as AHI <5/h in the PPP night was observed in 15 (51.7 %) patients, with a better rate in female than male patients (9/12 vs. 6/17, respectively, p=0.03). Conclusions To our knowledge, this is the first study to examine the effect of prone positioning in the treatment of mild to moderate OSA. Application of PPP with a more comfortable design in a randomized clinical trial is required to investigate its long term effect in the treatment of mild to moderate OSA.
... Previous studies comparing the efficacy of TBT, or modifications of it, with the new generation of devices for PT indicate similar results. 1,9,16,[39][40][41][42][43][44][45][46] However, under study conditions with short-term follow-up, compliance is higher with the newer generation PT devices. Therefore, greater therapeutic effectiveness seems likely. ...
Article
Study objectives: In approximately 56% to 75% of patients with obstructive sleep apnea (OSA), the frequency and duration of apneas are influenced by body position. This is referred to as position-dependent OSA or POSA. Patients with POSA can be treated with a small device attached to either the neck or chest. These devices-a new generation of devices for positional therapy (PT)-provide a subtle vibrating stimulus that prevents patients adopting the supine position. The objectives of this study were to determine whether PT is effective in improving sleep study variables and sleepiness, and to assess compliance. Methods: A systematic review and meta-analysis. Results: Three prospective cohort studies and four randomized controlled trials were included in this review. Combined data for studies reporting on the effect of PT show that there was a mean difference of 11.3 events/h (54% reduction) in apnea-hypopnea index and 33.6% (84% reduction) in percentage total sleeping time in the supine position. The standardized mean difference for both parameters demonstrated a large magnitude of effect (> 0.8 in both cases). Conclusions: There is strong evidence that the new generation of devices for PT are effective in reducing the apnea-hypopnea index during short-term follow-up. These devices are simple-to-use for patients and clinicians and are reversible. Under study conditions with short-term follow-up, compliance is high; however, long-term compliance cannot be assessed because of lack of reliable data. Additional long-term, high-quality studies are needed to confirm the role of PT as a single or as a combination treatment modality for OSA patients and to assess long-term compliance.
Chapter
Frequent positional change during sleep or restless sleep is one of the common clinical manifestations in children and adults with obstructive sleep apnea syndrome (OSAS). However, there is little literature about positional change during sleep in OSAS. It is not yet known whether upper airway surgery for OSAS influences positional change during sleep. In addition, it is not well recognized what the effect of OSAS surgery is on the distribution of the different sleep positions during sleep. In children with OSAS, frequent positional change during sleep significantly decreased with the improvement of respiratory disturbances and arousals, while the proportion of sleep time spent in the supine position significantly increased after adenotonsillectomy. In adults with OSAS, frequent positional change during sleep also significantly reduced with the alleviation of respiratory parameters after successful upper airway surgery. However, no consistent outcomes related to the distribution of sleep position before and after OSAS surgery were found. Although it seems that there were no significant postoperative changes in supine sleep time in most adults with OSAS, postoperative changes in the proportion of sleep time spent in the supine position may occur in some patient groups. Further studies are required to confirm the effect of surgery on positional change during sleep and distribution of sleep position.
Chapter
During the past centuries, various techniques have been described to prevent patients from assuming the supine position such as an upright sleep posture, positional alarms, verbal instructions, tennis balls, vests, “shark fins” or special pillows. Different inventions have been patented over the years. Scientific research shows that positional therapy has a significant influence on the apnoea–hypopnoea index. These studies are predominantly performed as case series on a comparably small number of patients. The aim of this chapter is to provide an overview of the literature on positional therapy and its origin and evolution. A broad search strategy was run electronically in the MEDLINE, Embase and Google Scholar databases using synonyms for position, sleep apnoea, positional therapy and patents. Next to a great number of patents, 17 scientific studies were found which examined the effect of positional therapy on OSA. In this chapter we discuss the various techniques, results and compliance rates. Long-term compliance for positional therapy remains an issue, and although remarkable results have been shown using innovative treatment concepts for positional therapy, there is room for both technical improvement of the devices and for further long-term research.
Chapter
Positional patients are defined as obstructive sleep apnea (OSA) patients in whom respiratory disturbance index (RDI) or apnea-hypopnea index (AHI) is at least twice as high in the supine position than in the non-supine position. Positional therapy (the avoidance of the supine posture during sleep) is a simple behavioral therapy for mild and moderate sleep disordered breathing. In this chapter, we 1) provide an overview of position dependent sleep and positional therapy for sleep disordered breathing, 2) update the clinical evidence for positional therapy and position dependent sleep advances in sleep technology, and 3) discuss issues regarding implementing positional therapy.
Chapter
A limited number of studies focus on decreasing the severity of obstructive sleep apnoea by influencing sleep position. In these studies an object was strapped to the back (tennis balls, special vests) preventing patients from sleeping in supine position. Frequently, this was not successful due to arousals whilst turning from one position to the other, thereby disturbing sleep architecture and sleep quality. In this chapter we present a novel device for treating POSA patients. Patients older than 18 years with mild to moderate POSA slept with the sleep position trainer (SPT), strapped to the chest, for a month. SPT measures the body position and vibrates when the patient lies in supine position. Thirty-one patients (mean age 48.1 ± 11.0 years; mean body mass index 27.0 ± 3.7 kg m−2) completed the study protocol. The median percentage of supine sleeping time decreased from 49.9 to 0.0 % (p < 0.001). The median AHI decreased from 16.4 to 5.2 (p < 0.001). Fifteen patients developed an overall AHI below five. Epworth Sleepiness Scale decreased significantly. Functional Outcomes of Sleep Questionnaire increased significantly. Compliance was found to be 100 %. The sleep position trainer applied for 1 month is a highly successful and well-tolerated treatment for POSA patients, which diminishes subjective sleepiness and improves sleep-related quality of life without negatively affecting sleep efficiency.
Chapter
Snoring is an acoustic phenomenon that affects approximately 20–40 % of the general population [1]. It is caused by vibration of tissue structures in the upper airway during sleep [2, 3]. Non-apneic snoring has been shown to be associated with clinical conditions such as depression and excessive daytime sleepiness in adults and may also have clinical implications in the development of hypertension, ischemic heart disease, and cerebrovascular diseases [1, 4]. In this chapter, the prevalence of position dependency in non-apneic snorers and the influence of various factors such as BMI, neck circumference, age, gender, and sleep efficiency on sleeping position will be discussed.
Article
The aims of the present study were twofold. We sought to compare two methods of titrating the level of continuous positive airway pressure (CPAP) - auto-adjusting titration and titration using a predictive equation - with full-night manual titration used as the benchmark. We also investigated the reliability of the two methods in patients with obstructive sleep apnea syndrome (OSAS). Twenty consecutive adult patients with OSAS who had successful, full-night manual and auto-adjusting CPAP titration participated in this study. The titration pressure level was calculated with a previously developed predictive equation based on body mass index and apnea-hypopnea index. The mean titration pressure levels obtained with the manual, auto-adjusting, and predictive equation methods were 9.0 +/- 3.6, 9.4 +/- 3.0, and 8.1 +/- 1.6 cm H2O,respectively. There was a significant difference in the concordance within the range of +/- 2 cm H2O (p = 0.019) between both the auto-adjusting titration and the titration using the predictive equation compared to the full-night manual titration. However, there was no significant difference in the concordance within the range of +/- 1 cm H2O (p > 0.999). When compared to full-night manual titration as the standard method, auto-adjusting titration appears to be more reliable than using a predictive equation for determining the optimal CPAP level in patients with OSAS.
Article
Background: Positional obstructive sleep apnoea (POSA), defined as a supine apnoea-hypopnoea index (AHI) twice or more as compared to the AHI in the other positions, occurs in 56 % of obstructive sleep apnoea patients. Positional therapy (PT) is one of several available treatment options for these patients. So far, PT has been hampered by compliance problems, mainly because of the usage of bulky masses placed in the back. In this article, we present a novel device for treating POSA patients. Methods: Patients older than 18 years with mild to moderate POSA slept with the Sleep Position Trainer (SPT), strapped to the chest, for a period of 29 ± 2 nights. SPT measures the body position and vibrates when the patient lies in supine position. Results: Thirty-six patients were included; 31 patients (mean age, 48.1 ± 11.0 years; mean body mass index, 27.0 ± 3.7 kg/m(2)) completed the study protocol. The median percentage of supine sleeping time decreased from 49.9 % [20.4-77.3 %] to 0.0 % [range, 0.0-48.7 %] (p < 0.001). The median AHI decreased from 16.4 [6.6-29.9] to 5.2 [0.5-46.5] (p < 0.001). Fifteen patients developed an overall AHI below five. Sleep efficiency did not change significantly. Epworth Sleepiness Scale decreased significantly. Functional Outcomes of Sleep Questionnaire increased significantly. Compliance was found to be 92.7 % [62.0-100.0 %]. Conclusions: The Sleep Position Trainer applied for 1 month is a highly successful and well-tolerated treatment for POSA patients, which diminishes subjective sleepiness and improves sleep-related quality of life without negatively affecting sleep efficiency. Further research, especially on long-term effectiveness, is ongoing.
Article
Background: The severity of obstructive sleep apnea (OSA) is, in 56–75 % influenced by body position. The prevalence of positional OSA (POSA) decreases as the severity of OSA increases, and 70–80% of POSA patients have mild to moderate OSA. Materials and methods: The literature on POSA is reviewed. Many definitions have been applied using modified versions of Cartwright’s criteria (a difference in apnea index of 50% or more between supine and non-supine positions). Others have proposed a distinction among POSA patients (PP) between supine-isolated OSA (non-supine apnea–hypopnea index, AHI,?< 5) and supine-predominant OSA (non-supine AHI?≥ 5). Results: In PP, positional therapy (PT) as a standalone treatment or in combination with other treatment modalities has proven to be effective. To achieve high compliance, proper selection of PP suitable for treatment with PT remains of high importance. In 2014, the Amsterdam Positional OSA Classification (APOC) was proposed, which can be used to identify suitable candidates for PT. Conclusion: There is strong evidence that PT is effective in reducing AHI during short- and long-term follow-up in PP, and can be used as a standalone treatment or in combination with other treatment modalities. Recently, several studies have pointed out the complexity of POSA pathophysiology, which leaves room for more understanding and knowledge of this underestimated phenomenon in the future. © 2018 Springer Medizin Verlag GmbH, ein Teil von Springer Nature
Article
To assess the effect of uvulopalatopharyngoplasty (UPPP) on positional dependency in patients with obstructive sleep apnea (OSA). Retrospective analysis. Tertiary care university hospital. Ninety-six patients who underwent UPPP because of OSA from June 1, 2004, through July 31, 2008, were included. Both preoperative and postoperative attended full-night polysomnography were conducted in all patients. Positional dependency was diagnosed if the patient's apnea-hypopnea index score in the supine position was more than twice as high as that in the lateral position. Position-specific outcomes of UPPP, such as the success rates in the supine or lateral position, were assessed, as well as overall treatment outcomes. The outcomes were also analyzed according to the severity level of the apnea-hypopnea index in each position. The change of positional dependency after UPPP was evaluated. The apnea-hypopnea index score in the lateral position was markedly reduced after UPPP in position-independent patients (P = .02). However, the overall success rates were only 31.8% and 34.6% in patients with and without positional dependency, respectively. The success rate in the lateral position was 68.2% in position-independent patients and 32.7% in position-dependent patients (P = .01). In addition, 14 of 22 patients with position-independent OSA (64%) gained positional dependency after UPPP. Uvulopalatopharyngoplasty is successful treatment for obstructive events occurring in the lateral sleep position, especially in patients without positional dependency. This implies that patients who have become position dependent may benefit from positional therapy after UPPP.
Article
The purpose of this study was to evaluate the changes of position during sleep as determined by polysomnography before and after upper airway surgery for obstructive sleep apnea syndrome in patients with no response to surgery ("nonresponse group") and in those who did have a response to surgery ("response group"). We analyzed a total of 106 polysomnograms from 53 subjects and compared the preoperative-postoperative differences in the frequency of positional changes during sleep and the distribution of sleep positions between the nonresponse group (n = 25) and the response group (n = 28). Surgical response was defined as a greater than 50% decrease in the postoperative apnea-hypopnea index. The positional change index in the response group was significantly reduced (from 4.2 +/- 3.8 to 2.6 +/- 1.6; p = 0.038), whereas the positional change index in the nonresponse group did not significantly change (from 3.4 +/- 2.0 to 3.4 +/- 2.1; p = 0.861). The proportion of sleep time spent in the supine position did not significantly change in the nonresponse group (from 62.4% +/- 18.1% to 60.5% +/- 21.3%; p = 0.904) or the response group (from 55.5% +/- 23.9% to 60.1% +/- 23.1%; p = 0.412). The frequency of positional changes during sleep was significantly decreased with the improvement of respiratory disturbances and arousals in the response group after upper airway surgery.
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The aim of this study was to investigate optimal continuous positive airway pressure (CPAP) level, to examine the factors affecting optimal CPAP level, and to develop a predictive equation for optimal CPAP level in Korean patients with obstructive sleep apnea syndrome (OSAS). A total of 202 patients with OSAS who underwent successful manual titration for CPAP treatment were included in this study. Correlations between the optimal CPAP level and baseline data including anthropometric and polysomnographic variables were analyzed. A predictive equation for optimal CPAP level was developed based on anthropometric and polysomonographic data. The mean optimal CPAP level in 202 patients with OSAS was 7.8±2.3 cm H(2)O. The mean optimal CPAP level in the mild, moderate, and severe OSAS groups was 6.0±1.3, 7.4±1.9, and 9.1±2.1 cm H(2)O, respectively. The apneahypopnea index (AHI) (r=0.595, P<0.001), arousal index (r=0.542, P<0.001), minimal SaO(2) (r=-0.502, P<0.001), body mass index (BMI) (r=0.494, P<0.001), neck circumference (r=0.265, P<0.001), and age (r=-0.164, P=0.019) were significantly correlated with optimal CPAP level. The best predictive equation according to stepwise multiple linear regression analysis was: Optimal CPAP level (cm H(2)O)=0.681+(0.205×BMI)+(0.040×AHI). Forty-two percent of the variance in the optimal CPAP level was explained by this equation (R(2)=0.42, P<0.001). A predictive equation for optimal CPAP level in Korean patients with OSAS was developed using AHI and BMI, which can be easily measured during the diagnostic process.
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The aggravating effect of the supine body position on breathing abnormalities during sleep was recognized from the earliest studies on sleep breathing disorders. Most of the anatomical and physiological correlates of this phenomenon appear to be due to the effect of gravity on the upper airway. Although few articles have been published on this topic, it has been shown in a large population of obstructive sleep apnoea (OSA) patients that more than half of them are Positional Patients, i.e. they have at least twice as many apnoeas/hypopnoeas during sleep in the supine posture as in the lateral position. This positional phenomenon is influenced by factors such as Respiratory Disturbances Index (RDI), Body Mass Index (BMI), age and sleep stages. The sleep supine posture not only increases the frequency of the abnormal breathing events but also their severity. This sleep posture also has a detrimental effect on snoring, as well as on the optimal CPAP pressure.Positional Therapy, i.e. the avoidance of the supine posture during sleep, is a simple behavioural therapy for many mild to moderate OSA patients. Unfortunately, only a few studies, including only a few patients, have investigated this form of therapy. Although the results of these studies are promising, the lack of a reliable long-term evaluation of its efficacy is perhaps an important reason why this form of therapy has not been widely accepted. Since mild to moderate OSA patients are the majority of the OSA patients and since without treatment, a large percentage of them will develop a more severe form of the disease, a thorough evaluation with a major emphasis on the long-term effectiveness of this form of therapy is urgently needed.
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Sixty male patients all with apnea plus hypopnea indices (A + HI) above 12.5, who met a criterion of positionality by having two or more times the rate of these events during supine sleep in comparison to their lateral sleep rate, were randomly assigned to one of four treatments for 8 weeks. All were restudied for two nights, one with and one without treatment devices. On treatment more than half the patients in each group reduced their A + HI to within normal limits and a third remained WNL without the use of devices. Half of those trained to sleep in the lateral position with the help of an alarm maintained this learning without the alarm as did half of those who were encouraged to learn this sleep posture on their own. There is an additive effect for the positional patient from wearing a tongue retaining device (TRD) if they continue to sleep in the supine position. Factors associated with successful treatment include overall severity, severity in the lateral position, weight, weight change, nasal patency and motivation to help their condition.
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Thirty male patients evaluated sequentially for sleep apnea syndrome by all-night clinical polysomnography were compared for apnea plus hypopnea index (A + HI) during the time in the side versus time in the back sleep posture. For 24 subjects of this sample, who occupied both major body positions during the evaluation night, the apnea index was found to be twice as high during the time spent sleeping on their backs as it was when they slept in the side position. This difference is reliable and inversely related to obesity. Five patients meeting diagnostic criteria for sleep apnea on an all-night basis fell within normal limits while in the side sleep position. This suggests sleep position adjustment may be a viable treatment for some nonobese sleep apnea patients.
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The aim of this study was to compare the relative efficacy of continuous positive airway pressure (CPAP) and positional treatment in the management of positional obstructive sleep apnea (OSA), using objective outcome measures. A prospective, randomized, single blind crossover comparison of CPAP and positional treatment for 2 weeks each. A university teaching hospital. Thirteen patients with positional OSA, aged (mean+/-SD) 51+/-9 years, with an apnea-hypopnea index (AHI) of 17+/-8. (1) Daily Epworth Sleepiness Scale scores; (2) overnight polysomnography, an objective assessment of sleep quality and AHI; (3) maintenance of wakefulness testing; (4) psychometric test battery; (5) mood scales; (6) quality-of-life questionnaires; and (7) individual patient's treatment preference. Positional treatment was highly effective in reducing time spent supine (median, 0; range, 0 to 32 min). The AHI was lower (mean difference, 6.1; 95% confidence interval [CI], 2 to 10.2; p = 0.007), and the minimum oxygen saturation was higher (4%; 95% CI, 1% to 8%; p = 0.02) on CPAP as compared with positional treatment. There was no significant difference, however, in sleep architecture, Epworth Sleepiness Scale scores, maintenance of wakefulness testing sleep latency, psychometric test performance, mood scales, or quality-of-life measures. Positional treatment and CPAP have similar efficacy in the treatment of patients with positional OSA.
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We examined the effects of cervical position on the Obstructive Sleep Apnea Syndrome (OSAS) through the use of a custom-designed cervical pillow which promoted neck extension. Twelve subjects with OSAS were recruited from a tertiary sleep disorder clinic population. Of the twelve subjects, three had mild cases of OSAS, four had moderate cases, and the remaining five had severe cases. The subjects used their usual pillows during two consecutive recorded baseline nights in our laboratory. The subjects then used the cervical pillow for five days at home, and returned for two consecutive recorded nights at our laboratory while using the cervical pillow. During the nights in our laboratory, the subjects completed questionnaires, were videotaped to record head and body position, and had their breathing parameters recorded during sleep. Subjects with mild OSAS cases had a non-significant improvement in the severity of their snoring and a significant improvement in their respiratory disturbance index with the cervical pillow, while subjects with moderate OSAS cases showed no improvement in these parameters. Subjects with severe OSAS cases showed slight improvement in some measures of their abnormal respiratory events during the experimental period.
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Sleep-disordered breathing (SDB) is common, but largely undiagnosed in the general population. Information on demographic patterns of SDB occurrence and its predictive factors in the general population is needed to target high-risk groups that may benefit from diagnosis. The sample comprised 5615 community-dwelling men and women aged between 40 and 98 years who were enrolled in the Sleep Heart Health Study. Data were collected by questionnaire, clinical examinations, and in-home polysomnography. Sleep-disordered breathing status was based on the average number of apnea and hypopnea episodes per hour of sleep (apnea-hypopnea index [AHI]). We used multiple logistic regression modeling to estimate cross-sectional associations of selected participant characteristics with SDB defined by an AHI of 15 or greater. Male sex, age, body mass index, neck girth, snoring, and repeated breathing pause frequency were independent, significant correlates of an AHI of 15 or greater. People reporting habitual snoring, loud snoring, and frequent breathing pauses were 3 to 4 times more likely to have an AHI of 15 or greater vs an AHI less than 15, but there were weaker associations for other factors with an AHI of 15 or greater. The odds ratios (95% confidence interval) for an AHI of 15 or greater vs an AHI less than 15 were 1.6 and 1.5, respectively, for 1-SD increments in body mass index and neck girth. As age increased, the magnitude of associations for SDB and body habitus, snoring, and breathing pauses decreased. A significant proportion of occult SDB in the general population would be missed if screening or case finding were based solely on increased body habitus or male sex. Breathing pauses and obesity may be particularly insensitive for identifying SDB in older people. A better understanding of predictive factors for SDB, particularly in older adults, is needed.
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Sleep-disordered breathing (SDB) is both prevalent and associated with serious chronic illness. The incidence of SDB and the effect of risk factors on this incidence are unknown. To determine the 5-year incidence of SDB overall and as influenced by risk factors. Of the 1149 participants in the Cleveland Family Study, those aged 18 years or older, from either case or control families, who had 2 in-home sleep studies 5 years apart. The first had to have been performed before June 30, 1997, and had to have normal results (apnea hypopnea index [AHI] <5). Data included questionnaire information on medical and family history, SDB symptoms; measurement of height, weight, blood pressure, waist and hip circumference, and serum cholesterol concentration; and overnight sleep monitoring. Apnea hypopnea index, defined as number of apneas and hypopneas per hour of sleep. Sleep-disordered breathing was defined by an AHI of at least 10 (mild to moderate) or of at least 15 (moderate). Forty-seven (16%) of 286 eligible participants, (95% confidence interval [CI], 13%-21%) had a second-study AHI of at least 10 and 29 (10%) participants (95% CI, 7%-14%) had a second-study AHI result of at least 15. For the AHI results of at least 15, we estimate that about 2.5% may represent test variability. By ordinal logistic regression analysis, AHI was significantly associated with age (odds ratio [OR] per 10-year increase, 1.79; 95% CI, 1.41-2.27), body mass index (BMI; OR per 1-unit increase, 1.14; 95% CI, 1.10-1.19), sex (OR for men vs women, 4.12; 95% CI, 2.29-7.43), waist-hip ratio (OR per 0.1 unit increase, 1.61; 95% CI, 1.04-2.28), and serum cholesterol concentration (OR per 10-mg/dL [0.25-mmol/L] increase, 1.11; 95% CI, 1.03-1.19). Interactions were noted between age and both sex (P =.003) and BMI (P =.05). The OR for increased AHI per 10-year age increase was 2.41 in women (95% CI, 1.78-3.26) and 1.15 in men (95% CI, 0.78-1.68), with the male vs female OR decreasing from 5.04 (95% CI, 2.19-11.6) at age 30 years to 0.54 (95% CI, 0.15-1.99) at age 60 years. The OR for increased AHI per 1-unit increase in BMI decreased from 1.21 (95% CI, 1.11-1.31) at age 20 years to 1.05 (95% CI, 0.96-1.15) at age 60 years. The 5-year incidence is about 7.5% for moderately severe SDB and 16% (or less) for mild to moderately severe SDB. Incidence of SDB is influenced independently by age, sex, BMI, waist-hip ratio, and serum cholesterol concentration. Predominance in men diminishes with increasing age, and by age 50 years, incidence rates among men and women are similar. The effect of BMI also decreases with age and may be negligible at age 60 years.
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This study aimed to evaluate the effectiveness of elevated posture in the management of obstructive sleep apnea (OSA). Fourteen subjects presenting with mild-moderate OSA, (apnea-hypopnea index [AHI] 10 to 60/h), were included in a randomized crossover investigation. A shoulder-head elevation pillow (SHEP) was compared with nasal continuous positive airway pressure (nCPAP) therapy. Treatment success was defined as AHI<or=10/h and partial success as AHI>10<16/h. Four subjects achieved treatment success with the SHEP and three achieved partial success. The remaining seven subjects were treatment failures. In contrast, success was achieved with nCPAP in 12 subjects. One subject achieved partial success and one was a treatment failure. With the SHEP, the mean AHI decreased from 27+/-12/h to 21+/-17/h. With nCPAP, the mean AHI was 5+/-3/h; (p=0.008 for the difference between treatments). Although somewhat variable, these data provide evidence that elevated posture during sleep is helpful in the management of OSA in some individuals. Results support the use of elevated posture as second-line therapy in the management of OSA. However, no relationships could be identified between baseline data, including the identification of positional OSA, and objective outcomes that might predict patients who are likely to benefit from treatment in an elevated position.
Elevated posture for the management of obstructive sleep apnea
  • Skinner
Sleep apnea avoidance pillow effects on obstructive sleep apnea syndrome and snoring
  • Zuberi