Combination Therapy for Obstructive Sleep Apnea in Order to Achieve Complete Disease Alleviation: from Taboo to New Standard of Care?

ABSTRACT Sleep disordered breathing (SDB) affects 1 in 10 children in the United States and poses a growing threat to childhood health. Although tonsillectomy and adenoidectomy is considered the standard of care for treatment of pediatric SDB, up to 25% of children present with persistent symptoms after surgery. Success of treatment modalities, such as continuous positive airway pressure (CPAP) is affected by compliance. Management of residual SDB is a complex, and often controversial topic. Here we discuss options for managing childhood SDB that persists after initial management with tonsillectomy. How to cite this article Isaiah A, Mitchell RB. Pediatric Obstructive Sleep Apnea: Surgical Techniques beyond Tonsillectomy and Adenoidectomy. Int J Head Neck Surg 2016;7(2):109-114.

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Poster 366 Admission Screening for Obstructive Sleep Apnea during Inpatient Stroke Rehabilitation, A New Standard of Care: A Case Report

PM&R ◽

10.1016/j.pmrj.2014.08.745 ◽

2014 ◽

Vol 6 (9) ◽

pp. S313-S314

Author(s):

Jennifer R. Knowlton ◽

Jessica Hanson ◽

William Doss

Keyword(s):

Obstructive Sleep Apnea ◽

Case Report ◽

Sleep Apnea ◽

Stroke Rehabilitation ◽

Standard Of Care ◽

Admission Screening ◽

Obstructive Sleep

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The Impact of Empagliflozin on Obstructive Sleep Apnea, Cardiovascular, and Renal Outcomes: An Exploratory Analysis of the EMPA-REG OUTCOME Trial

10.2337/figshare.12970550.v1 ◽

2020 ◽

Author(s):

Ian J. Neeland ◽

Bjorn Eliasson ◽

Takatoshi Kasai ◽

Nikolaus Marx ◽

Bernard Zinman ◽

...

Keyword(s):

Obstructive Sleep Apnea ◽

Sleep Apnea ◽

Cox Regression ◽

Standard Of Care ◽

Renal Outcomes ◽

Medication Discontinuation ◽

Obstructive Sleep ◽

Outcome Trial ◽

New Diagnosis ◽

The Impact

Objective: To explore the effects of empagliflozin on the incidence of obstructive sleep apnea (OSA) and its effects on metabolic, cardiovascular (CV), and renal outcomes among participants with or without OSA in the EMPA-REG OUTCOME trial. Research Design and Methods: Participants with diabetes and CVD were randomized to empagliflozin (10/25mg), or placebo daily in addition to standard of care. OSA was assessed by investigator-reports using MedDRA-18.0 and CV outcomes were independently adjudicated. Analyses were performed using multivariable-adjusted Cox regression models. Results: OSA was reported in 391/7020 (5.6%) at baseline. Those with OSA were more likely to be male (83 vs 71%) and have moderate-severe obesity (BMI ≥35 kg/m2; 55 vs 18%). Over a median 3.1 years, empagliflozin had similar placebo-adjusted reductions in HbA1c, waist circumference, and systolic blood pressure regardless of OSA status, but a larger effect on weight (adjusted mean±SE difference at week 52: OSA/no OSA: -2.9±0.5/-1.9±0.1 kg). Incidence of 3P-MACE, CV death, heart failure hospitalization, and incident or worsening nephropathy in the placebo-group was 1.2-2.0 fold higher for those with baseline OSA compared to those without. Empagliflozin significantly reduced the risk for outcomes regardless of OSA status (p-interaction all >0.05). Fifty patients reported a new diagnosis of OSA through 7 days after medication discontinuation and this occurred less often with empagliflozin treatment (HR 0.48 [95% CI 0.27, 0.83]). Conclusions: In EMPA-REG OUTCOME, participants with OSA had greater comorbidity and higher frequency of CV and renal events. Empagliflozin had favorable effects on risk factors and CV and renal outcomes regardless of preexisting OSA and may also reduce the risk for new-onset OSA.

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The Impact of Empagliflozin on Obstructive Sleep Apnea, Cardiovascular, and Renal Outcomes: An Exploratory Analysis of the EMPA-REG OUTCOME Trial

10.2337/figshare.12970550 ◽

2020 ◽

Author(s):

Ian J. Neeland ◽

Bjorn Eliasson ◽

Takatoshi Kasai ◽

Nikolaus Marx ◽

Bernard Zinman ◽

...

Keyword(s):

Obstructive Sleep Apnea ◽

Sleep Apnea ◽

Cox Regression ◽

Standard Of Care ◽

Renal Outcomes ◽

Medication Discontinuation ◽

Obstructive Sleep ◽

Outcome Trial ◽

New Diagnosis ◽

The Impact

Objective: To explore the effects of empagliflozin on the incidence of obstructive sleep apnea (OSA) and its effects on metabolic, cardiovascular (CV), and renal outcomes among participants with or without OSA in the EMPA-REG OUTCOME trial. Research Design and Methods: Participants with diabetes and CVD were randomized to empagliflozin (10/25mg), or placebo daily in addition to standard of care. OSA was assessed by investigator-reports using MedDRA-18.0 and CV outcomes were independently adjudicated. Analyses were performed using multivariable-adjusted Cox regression models. Results: OSA was reported in 391/7020 (5.6%) at baseline. Those with OSA were more likely to be male (83 vs 71%) and have moderate-severe obesity (BMI ≥35 kg/m2; 55 vs 18%). Over a median 3.1 years, empagliflozin had similar placebo-adjusted reductions in HbA1c, waist circumference, and systolic blood pressure regardless of OSA status, but a larger effect on weight (adjusted mean±SE difference at week 52: OSA/no OSA: -2.9±0.5/-1.9±0.1 kg). Incidence of 3P-MACE, CV death, heart failure hospitalization, and incident or worsening nephropathy in the placebo-group was 1.2-2.0 fold higher for those with baseline OSA compared to those without. Empagliflozin significantly reduced the risk for outcomes regardless of OSA status (p-interaction all >0.05). Fifty patients reported a new diagnosis of OSA through 7 days after medication discontinuation and this occurred less often with empagliflozin treatment (HR 0.48 [95% CI 0.27, 0.83]). Conclusions: In EMPA-REG OUTCOME, participants with OSA had greater comorbidity and higher frequency of CV and renal events. Empagliflozin had favorable effects on risk factors and CV and renal outcomes regardless of preexisting OSA and may also reduce the risk for new-onset OSA.

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0611 Screening for Obstructive Sleep Apnea in the Bariatric Surgery Population

SLEEP ◽

10.1093/sleep/zsaa056.608 ◽

2020 ◽

Vol 43 (Supplement_1) ◽

pp. A234-A234

Author(s):

K Kreitinger ◽

M M Lui ◽

R Owens ◽

C Schmickl ◽

E Grunvald ◽

...

Keyword(s):

Bariatric Surgery ◽

Obstructive Sleep Apnea ◽

Sleep Apnea ◽

Statistical Significance ◽

Preoperative Evaluation ◽

Standard Of Care ◽

Screening Tools ◽

Apnea Hypopnea Index ◽

Sleep Study ◽

Obstructive Sleep

Abstract Introduction Obstructive sleep apnea (OSA) is prevalent in the bariatric surgery population and has been associated with increased perioperative risk, especially if OSA is moderate-severe (apnea-hypopnea index ≥ 15/h). Consequently, screening for OSA is recommended as part of the preoperative evaluation. Several screening tools for OSA have been developed; however, some tools lack validation and their relative performance is unclear. The purpose of this study was to compare four existing screening tools (Epworth Sleepiness Scale (ESS), STOP-BANG, NO-OSAS, and No-Apnea) with regards to the ability to identify patients with moderate-severe OSA among bariatric surgery patients. Methods We retrospectively reviewed data from Jan 2015 to Mar 2019 for adult patients presenting consecutively to UC San Diego for first-time bariatric surgery who had undergone a home or in-lab sleep study (within one year of the initial encounter for bariatric surgery), which is our standard of care. We compared the accuracy of the four screening tools for detecting moderate-severe OSA based on the area under the receiver operating characteristic curves (AUC). Subgroup analyses were explored based on sex, BMI, and ethnicity (Hispanic/Latino vs non-Hispanic/Latino). Results Of the 214 patients (83.2% female, median age 39 years) included in the study, 45.4% had moderate-severe OSA. STOP-BANG (AUC 0.75 [95%CI: 0.68 to 0.81]) and NO-OSAS (AUC 0.76 [95%CI: 0.69 to 0.82]) had similar performance (p 0.62); both performed significantly better than the ESS (AUC 0.61 [95%CI: 0.54 to 0.68]; p 0.02 for both). STOP-BANG and NO-OSAS tended to perform better in the female vs male subgroup, but this finding did not reach statistical significance. Conclusion STOP-BANG and NO-OSAS are superior to the ESS when screening bariatric surgery patients for moderate-severe OSA. In future analyses we will further explore if adjustments of standard cut-offs improve test characteristics (i.e. sensitivity/specificity) when screening bariatric surgery patients (analyses ongoing). Support None.

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Combination therapy with mandibular advancement and expiratory positive airway pressure valves reduces obstructive sleep apnea severity

SLEEP ◽

10.1093/sleep/zsz119 ◽

2019 ◽

Vol 42 (8) ◽

Cited By ~ 6

Author(s):

Victor Lai ◽

Benjamin K Tong ◽

Carolin Tran ◽

Andrea Ricciardiello ◽

Michelle Donegan ◽

...

Keyword(s):

Obstructive Sleep Apnea ◽

Sleep Apnea ◽

Combination Therapy ◽

Airway Pressure ◽

Positive Airway Pressure ◽

Mandibular Advancement ◽

Apnea Hypopnea Index ◽

Mandibular Advancement Splint ◽

Obstructive Sleep ◽

Expiratory Positive Airway Pressure

AbstractStudy ObjectivesMandibular advancement splint (MAS) therapy is a well-tolerated alternative to continuous positive airway pressure for obstructive sleep apnea (OSA). Other therapies, including nasal expiratory positive airway pressure (EPAP) valves, can also reduce OSA severity. However, >50% of patients have an incomplete or no therapeutic response with either therapy alone and thus remain at risk of adverse health outcomes. Combining these therapies may yield greater efficacy to provide a therapeutic solution for many incomplete/nonresponders to MAS therapy. Thus, this study evaluated the efficacy of combination therapy with MAS plus EPAP in incomplete/nonresponders to MAS alone.MethodsTwenty-two people with OSA (apnea–hypopnea index [AHI] = 22 [13, 42] events/hr), who were incomplete/nonresponders (residual AHI > 5 events/hr) on an initial split-night polysomnography with a novel MAS device containing an oral airway, completed an additional split-night polysomnography with MAS + oral EPAP valve and MAS + oral and nasal EPAP valves (order randomized).ResultsCompared with MAS alone, MAS + oral EPAP significantly reduced the median total AHI, with further reductions with the MAS + oral/nasal EPAP combination (15 [10, 34] vs. 10 [7, 21] vs. 7 [3, 13] events/hr, p < 0.01). Larger reductions occurred in supine nonrapid eye movement AHI with MAS + oral/nasal EPAP combination therapy (ΔAHI = 23 events/hr, p < 0.01). OSA resolved (AHI < 5 events/hr) with MAS + oral/nasal EPAP in nine individuals and 13 had ≥50% reduction in AHI from no MAS. However, sleep efficiency was lower with MAS + oral/nasal EPAP versus MAS alone or MAS + oral EPAP (78 ± 19 vs. 87 ± 10 and 88 ± 10% respectively, p < 0.05).ConclusionsCombination therapy with a novel MAS device and simple oral or oro-nasal EPAP valves reduces OSA severity to therapeutic levels for a substantial proportion of incomplete/nonresponders to MAS therapy alone.Clinical TrialsName: Targeted combination therapy: Physiological mechanistic studies to inform treatment for obstructive sleep apnea (OSA)URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=372279 Registration: ACTRN12617000492358 (Part C)

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