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Management of severe obstructive sleep apnea using mandibular advancement devices with auto continuous positive airway pressures.

Upadhyay R, Dubey A, Kant S, Singh BP - Lung India (2015 Mar-Apr)

Bottom Line: Treatment of the disease poses a great challenge not only for its diagnostic purpose but also for its treatment part.In about 29-83% of the patients, treatment is difficult because of non-compliance resulting due to high pressures, air leaks and other related issues.In such situations, alternative methods of treatment need to be looked for so as to ascertain better management.

View Article: PubMed Central - PubMed

Affiliation: Department of Pulmonary Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India.

ABSTRACT
The use of continuous positive airway pressures (CPAP) is considered standard treatment of moderate to severe obstructive sleep apnea (OSA). Treatment of the disease poses a great challenge not only for its diagnostic purpose but also for its treatment part. In about 29-83% of the patients, treatment is difficult because of non-compliance resulting due to high pressures, air leaks and other related issues. In such situations, alternative methods of treatment need to be looked for so as to ascertain better management. Mandibular advancement devices along with CPAP may show better treatment outcome in specific situations.

No MeSH data available.


Related in: MedlinePlus

(a) Computed tomography cross-section at the retropalatal low level without appliance; (b) Computed tomography cross-section at the retroglossal level with appliance
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Figure 2: (a) Computed tomography cross-section at the retropalatal low level without appliance; (b) Computed tomography cross-section at the retroglossal level with appliance

Mentions: A 55-yr-old obese, BMI of 33 kg/m2, male, attended our OPD for complaints of breathlessness, interrupted sleep pattern and choking episodes during sleep at night. He complains of dryness of mouth and lethargy throughout the day. He also complained of decreased alertness and difficulty in memory retention in past 1 year. On probing, we could elicit history of snoring from his family members. He gave evidences of excessive daytime sleepiness (EDS) with ESS = 20 [Table 1]. He was suffering for past 5 years, but his symptoms had increased in past 4 months after the lower respiratory tract infection. His younger brother, nearly of the same built, had similar symptoms, but more severe and had expired 8 months back during sleep; the cause of death was cardiac arrest. This prompted him to visit a physician and seek remedy. He was a hypertensive controlled on medications for past 4 years. There was no family history of hypertension or diabetes in family. He was a non-diabetic and his thyroid profile was within normal limits. His fasting lipid profile was deranged with total cholesterol 195, HDL-C 38, LDL-C 115 and triglycerides 209. His liver and kidney functions were found to be within normal limits. He had been an ex-smoker, hence a pulmonary function test was performed to deduce the cause of his breathlessness, but the results were within normal limits. He did not give any history of orthopnea, pedal edema or palpitations. Echocardiography was done and was found to be inconclusive. An otolaryngological examination was done to look for anatomical cause for obstruction. On examination, he was found to have a Mallampati Grade 4 with bulky tongue and enlarged uvula >2.5 cm. Full night polysomnography [Table 2] was done to diagnose and evaluate the severity of OSA. His apnea hypopnea index (AHI) was found to be 66.8/h with average saturation of 87% during sleep. His titration study to decide the CPAP to be applied could not be done as he could not tolerate the applied pressure of 12.7 cm of water. In order to reduce the obstruction, uvulopalatopharyngoplasty (UPPP) was planned. On pre-anesthtic evaluation he was found to be unfit for surgery. He was then advised for the mandibular advancement device application techniques along with autoPAP [Table 3], which showed a reduction in required airway pressure by 33% on day 1 and 51% on day 90. This time when used along with mandibuar advancement device he was able to tolerate the CPAP due to the widening of the airways as shown by change in the sagittal dimensions at various levels [Figures 1 and 2, Table 4]. He showed a tremendous response with the use of this device and with regular judicious use of MAD [Figure 3] with an autoPAP, he could also reduce his weight by 9 kg in the same duration which further added to the excellent outcome. Simultaneous use of MAD and autoPAP has been shown to be very effective in overcoming the obstruction and increasing tolerability and compliance in severe OSA, where the oral anatomy is the cause of occlusion in airway passages.


Management of severe obstructive sleep apnea using mandibular advancement devices with auto continuous positive airway pressures.

Upadhyay R, Dubey A, Kant S, Singh BP - Lung India (2015 Mar-Apr)

(a) Computed tomography cross-section at the retropalatal low level without appliance; (b) Computed tomography cross-section at the retroglossal level with appliance
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4372871&req=5

Figure 2: (a) Computed tomography cross-section at the retropalatal low level without appliance; (b) Computed tomography cross-section at the retroglossal level with appliance
Mentions: A 55-yr-old obese, BMI of 33 kg/m2, male, attended our OPD for complaints of breathlessness, interrupted sleep pattern and choking episodes during sleep at night. He complains of dryness of mouth and lethargy throughout the day. He also complained of decreased alertness and difficulty in memory retention in past 1 year. On probing, we could elicit history of snoring from his family members. He gave evidences of excessive daytime sleepiness (EDS) with ESS = 20 [Table 1]. He was suffering for past 5 years, but his symptoms had increased in past 4 months after the lower respiratory tract infection. His younger brother, nearly of the same built, had similar symptoms, but more severe and had expired 8 months back during sleep; the cause of death was cardiac arrest. This prompted him to visit a physician and seek remedy. He was a hypertensive controlled on medications for past 4 years. There was no family history of hypertension or diabetes in family. He was a non-diabetic and his thyroid profile was within normal limits. His fasting lipid profile was deranged with total cholesterol 195, HDL-C 38, LDL-C 115 and triglycerides 209. His liver and kidney functions were found to be within normal limits. He had been an ex-smoker, hence a pulmonary function test was performed to deduce the cause of his breathlessness, but the results were within normal limits. He did not give any history of orthopnea, pedal edema or palpitations. Echocardiography was done and was found to be inconclusive. An otolaryngological examination was done to look for anatomical cause for obstruction. On examination, he was found to have a Mallampati Grade 4 with bulky tongue and enlarged uvula >2.5 cm. Full night polysomnography [Table 2] was done to diagnose and evaluate the severity of OSA. His apnea hypopnea index (AHI) was found to be 66.8/h with average saturation of 87% during sleep. His titration study to decide the CPAP to be applied could not be done as he could not tolerate the applied pressure of 12.7 cm of water. In order to reduce the obstruction, uvulopalatopharyngoplasty (UPPP) was planned. On pre-anesthtic evaluation he was found to be unfit for surgery. He was then advised for the mandibular advancement device application techniques along with autoPAP [Table 3], which showed a reduction in required airway pressure by 33% on day 1 and 51% on day 90. This time when used along with mandibuar advancement device he was able to tolerate the CPAP due to the widening of the airways as shown by change in the sagittal dimensions at various levels [Figures 1 and 2, Table 4]. He showed a tremendous response with the use of this device and with regular judicious use of MAD [Figure 3] with an autoPAP, he could also reduce his weight by 9 kg in the same duration which further added to the excellent outcome. Simultaneous use of MAD and autoPAP has been shown to be very effective in overcoming the obstruction and increasing tolerability and compliance in severe OSA, where the oral anatomy is the cause of occlusion in airway passages.

Bottom Line: Treatment of the disease poses a great challenge not only for its diagnostic purpose but also for its treatment part.In about 29-83% of the patients, treatment is difficult because of non-compliance resulting due to high pressures, air leaks and other related issues.In such situations, alternative methods of treatment need to be looked for so as to ascertain better management.

View Article: PubMed Central - PubMed

Affiliation: Department of Pulmonary Medicine, King George's Medical University, Lucknow, Uttar Pradesh, India.

ABSTRACT
The use of continuous positive airway pressures (CPAP) is considered standard treatment of moderate to severe obstructive sleep apnea (OSA). Treatment of the disease poses a great challenge not only for its diagnostic purpose but also for its treatment part. In about 29-83% of the patients, treatment is difficult because of non-compliance resulting due to high pressures, air leaks and other related issues. In such situations, alternative methods of treatment need to be looked for so as to ascertain better management. Mandibular advancement devices along with CPAP may show better treatment outcome in specific situations.

No MeSH data available.


Related in: MedlinePlus