Titrated mandibular advancement versus positive pressure for sleep apnoea

ArticleinEuropean Respiratory Journal 34(4):914-20 · April 2009with15 Reads
DOI: 10.1183/09031936.00148208 · Source: PubMed
Abstract
The aim of this study was to compare mandibular advancement device (MAd) therapy and continuous positive airway pressure (CPAP) for obstructive sleep apnoea/hypopnoea syndrome (OSAHS) after one-night polysomnographic (PSG) titration of both treatments. 59 OSAHS patients (apnoea/hypopnoea index (AHI): 34+/-13 events x h(-1); Epworth scale: 10.6+/-4.5) were included in a crossover trial of 8 weeks of MAd and 8 weeks of CPAP after effective titration. Outcome measurements included home sleep study, sleepiness, health-related quality of life (HRQoL), cognitive tests, side-effects, compliance and preference. The median (interquartile range) AHI was 2 (1-8) events x h(-1) with CPAP and 6 (3-14) events x h(-1) with MAd (p<0.001). Positive and negative predictive values of MAd titration PSG for treatment success were 85% and 45%, respectively. Both treatments significantly improved subjective and objective sleepiness, cognitive tests and HRQoL. The reported compliance was higher for MAd (p<0.001) with >70% of patients preferring this treatment. These results support titrated MAd as an effective therapy in moderately sleepy and overweight OSAHS patients. Although less effective than CPAP, successfully titrated MAd was very effective at reducing the AHI and was associated with a higher reported compliance. Both treatments improved functional outcomes to a similar degree. One-night titration of MAd had a low negative predictive value for treatment success.
    • "A total of 82 papers were identified for analysis. These included trials comparing CPAP versus subtherapeutic (sham) CPAP , CPAP versus an oral placebo [40,[42][43][44][45][46][47][48][49], CPAP versus conservative or no therapy [17, 29,[50][51][52][53][54][55][56][57][58][59][60] , CPAP versus an oral ap- pliance [11, 12, 42, 57,[61][62][63][64][65][66][67][68][69], CPAP versus postural therapy [70][71][72][73], and CPAP alone assessing different means to modify adherence [15, 27, 37,[74][75][76][77][78][79][80][81][82]. The PRISMA chart summarizing the study flow is seen in Fig. 1. "
    [Show abstract] [Hide abstract] ABSTRACT: Background Obstructive sleep apnea (OSA) is a common disorder, and continuous airway positive pressure (CPAP) is considered to be the gold standard of therapy. CPAP however is known to have problems with adherence, with many patients eventually abandoning the device. The purpose of this paper is to assess secular trends in CPAP adherence over the long term to see if there have been meaningful improvements in adherence in light of the multiple interventions proposed to do so. MethodsA comprehensive systematic literature review was conducted using the Medline-Ovid, Embase, and Pubmed databases, searching for data regarding CPAP adherence over a twenty year timeframe (1994–2015). Data was assessed for quality and then extracted. The main outcome measure was reported CPAP non-adherence. Secondary outcomes included changes in CPAP non-adherence when comparing short versus long-term, and changes in terms of behavioral counseling. ResultsEighty-two papers met study inclusion/exclusion criteria. The overall CPAP non-adherence rate based on a 7-h/night sleep time that was reported in studies conducted over the twenty year time frame was 34.1 %. There was no significant improvement over the time frame. Behavioral intervention improved adherence rates by ~1 h per night on average. Conclusions The rate of CPAP adherence remains persistently low over twenty years worth of reported data. No clinically significant improvement in CPAP adherence was seen even in recent years despite efforts toward behavioral intervention and patient coaching. This low rate of adherence is problematic, and calls into question the concept of CPAP as gold-standard of therapy for OSA.
    Full-text · Article · Dec 2016
    • "A closer look at the evidence however reveals that surgery may indeed play a primary role in many patients with OSA. First, although a large number of RCTs have been published documenting the benefits of CPAP relative to sub-therapeutic (sham) CPAP , an oral placebo [32,[34][35][36][37][38][39][40][41][42][43], conservative or no therapy [9, 21, 42,[44][45][46][47][48][49][50][51][52][53], various oral appliances [3, 4, 35, 50,[54][55][56][57][58][59][60][61][62] , and postural therapy [63][64][65][66], numerous limitations of these RCTs must be considered. First among these is the short duration of follow-up that has been almost ubiquitous amongst CPAP trials, the vast majority having final assessments within weeks of the initial treatment, and only a small handful extending beyond 3 to 4 months [46, 56], 6 months [3, 52], 1 year [9, 21], or beyond [44]. "
    [Show abstract] [Hide abstract] ABSTRACT: Background Continuous positive airway pressure (CPAP) is typically recommended as first line therapy for obstructive sleep apnea, but the adherence rate of CPAP is problematic. This study’s objective was to systematically review the literature relating to CPAP as first line therapy for OSA and compare it to surgical literature on the same topic. Methods A systematic review was conducted according to PRISMA guidelines, examining Medline-Ovid, Embase, and Pubmed databases. The primary search objective was to identify all papers reporting the results of (1) randomized clinical trials (RCT) of CPAP for the treatment of adults with OSA; and (2) both randomized and non-randomized clinical trials and case series on the surgical treatment of OSA in adults. A PhD-level biostatistician first screened papers, and then those that met study criteria were retrieved and analyzed using standardized forms for each author. The primary outcomes were adherence rates of CPAP. Results A total of 82 controlled clinical trials for CPAP and 69 controlled and non-controlled surgery trials were identified for analysis. Variation in CPAP use within reported RCT trials were identified, and the majority of patients in the studies would eventually be considered non-adherent to CPAP. Conclusions When considering the numerous patient-related factors that come into play when CPAP is prescribed, the concept of CPAP as gold-standard therapy for OSA should be reconsidered. In many cases surgery can provide a better overall outcome. This study’s results suggest that certain patients with OSA may be managed more effectively with surgery than CPAP, without confounding issues of treatment adherence. Electronic supplementary material The online version of this article (doi:10.1186/s40463-016-0136-4) contains supplementary material, which is available to authorized users.
    Full-text · Article · Apr 2016
    • "As mentioned briefly above, outcomes in the present study appeared to be better for participants treated with a CAD/CAM MRD. In most studies, greater protrusion was associated with better improvement in AHI, nocturnal oxygen desaturations, and pharyngeal collapsibility [23,32,42,43]. The same gradual titration procedures were followed with the two MRD devices, but results with the non- CAD/CAM device were comparable to recent published data from a study with no systematic MRD titration [26]. "
    [Show abstract] [Hide abstract] ABSTRACT: Background: Mandibular repositioning devices (MRDs) are usually recommended as the first therapy option in patients with mild-to-moderate obstructive sleep apnoea (OSA). However, data on the long-term efficacy of MRDs are limited, not only in OSA patients who are noncompliant with continuous positive airway pressure (CPAP) but also in those with more severe OSA. The ORCADES study aimed to prospectively determine the long-term efficacy and tolerability of two custom-made Narval(™) MRDs for obstructive sleep apnoea-hypopnoea syndrome (OSAHS) patients. The interim 3- to 6-month data are reported. Methods: Eligible patients had OSAHS and had refused or were noncompliant with prescribed CPAP. Outcome measurements after gradual mandibular advancement titration included: apnoea-hypopnoea index (AHI), oxygen saturation, sleepiness, symptoms, quality of life, side effects and compliance. Results: A total of 369 patients were included. Overall, MRD treatment was successful (≥50% decrease in AHI) in 76.2% of the participants; complete response (AHI <10/h) was achieved in 63.5%. Severe OSAHS was effectively treated (AHI <15/h) in about 60% of the participants; 38% had complete symptom resolution. Mandibular repositioning devices significantly decreased subjective sleepiness, eliminated symptoms and improved quality of life. They were well tolerated and compliance was excellent. Only 8% of the participants stopped MRD treatment due to side effects. Conclusion: Custom-made Narval(™) MRDs are effective for mild to severe OSA in patients who refuse or are noncompliant with CPAP. They are well tolerated and have excellent compliance.
    Full-text · Article · Jun 2015
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