Medline ® Abstracts for References 32-35

OBJECTIVES: 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.

DESIGN: A prospective, randomized, single blind crossover comparison of CPAP and positional treatment for 2 weeks each.

SETTING: A university teaching hospital.

PATIENTS: Thirteen patients with positional OSA, aged (mean+/-SD) 51+/-9 years, with an apnea-hypopnea index (AHI) of 17+/-8.

MEASUREMENTS: (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.

RESULTS: 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.

CONCLUSION: Positional treatment and CPAP have similar efficacy in the treatment of patients with positional OSA.

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.

STUDY OBJECTIVES: Many positional therapy (PT) strategies are available for treating positional obstructive sleep apnea (OSA). PT is primarily supplied to selected patients as a secondary treatment option when other therapies have failed. To our knowledge this is the largest study to date to assess effectiveness and long-term compliance of PT (both commercial waistband and self-made constructions, mimicking the tennis ball technique) as primary treatment in patients with different positional OSA severities.

METHODS: PT was used by 53 patients, of which 40 patients underwent a follow-up polygraphic evaluation under treatment after a median time interval of 12 weeks. Patients were routinely contacted regarding their clinical status and treatment compliance.

RESULTS: PT was successful in 27 out of 40 patients (68%). Overall AHI reduced significantly from a median (interquartile range [IQR]) AHI of 14.5 (10.7-19.6) to 5.9 (3.1-8.5), p<0.001. The commercial waistband and self-made constructions were equally effective (median (IQR) reduction in overall AHI (Δ9.6 (5.5-11.9) andΔ6.8 (3.2-11.3) respectively), p = 0.22). Short-term compliance was good as most patients used PT more than 7 hours/night (mean 7.2±SD 1.4) and more than 6 days/ week (mean 6.5±SD 1.3). However, after mean 13±5 months, 26 patients (65%) reported they no longer used PT, especially patients with moderate positional OSA (89%).

CONCLUSIONS: On the short-term, PT using the tennis ball technique, is an easy method to treat most patients with positional OSA, showing significant reductions in AHI. Unfortunately, long-term compliance is low and close follow-up of patients on PT with regard to their compliance is necessary.

OBJECTIVE: To compare the effectiveness of positional therapy (PT) with the sleep position trainer (SPT) to oral appliance therapy (OAT) in patients with mild-to-moderate positional obstructive sleep apnea (POSA).

METHODS: Multicenter, prospective, randomized, controlled trial. Patients with mild-to-moderate POSA (apnea-hypopnea index (AHI)≥5 ≤ 30/hour sleep) were randomized for PT or OAT. Polysomnography was repeated after 3 months. Efficacy, adherence, mean disease alleviation (MDA), quality of life, dropouts and adverse events were evaluated.

RESULTS: A total of 177 patients were screened for the study; 99 underwent randomization and 81 completed the study. Intention-to-treat (ITT) analysis of median [IQR]AHI showed a reduction in the PT group from 13.0 [9.7-18.5]to 7.0 [3.8-12.8], p < 0.001 and in the OAT group from 11.7 [9.0-16.2]to 9.1 [4.9-11.7], p < 0.001. Mean adherence (≥4 h/night,≥5 days/week) was 89.3 ± 22.4% for SPT versus 81.3 ± 30.0% in OAT patients, p = 0.208.

CONCLUSIONS: Oral appliance therapy and positional therapy were equally effective in reducing the median AHI in patients with mild-to-moderate POSA. The results of this study have important implications for future OSA treatment guidelines and daily clinical practice. CLINICALTRIALS.

GOV NUMBER: NCT02045576.