06.05.2015
Sleep Review's webinar "Insourcing Versus Outsourcing Home Sleep Testing" is now available for on-demand viewing.
How it works: Oral appliance therapy (OAT) helps prevent the collapse of the tongue and soft tissues in the back of the throat by supporting the jaw in a forward position, keeping the airway open during sleep.
Other considerations: Patients with lower BMI and lower AHI have higher success rates with oral appliances. Bennett: It is important for sleep physicians to collaborate with a dentist who can conduct a thorough intraoral examination to assess candidacy for an oral appliance.
How it works: Worn on the back of the neck, Night Shift (by Advanced Brain Monitoring) begins to vibrate when users begin to sleep on their back and slowly increases in intensity until a position change occurs. New developments in 2014: Advanced Brain Monitoring received FDA clearance for Night Shift in June 2014. Concern: I can advise the patient to sleep on two tennis balls in a sock to stay off his back for a much cheaper price. Westbrook: Studies suggest that both efficacy and long-term compliance are poor with the tennis ball approach, plus the tennis ball approach does not provide compliance or effectiveness monitoring. Concern: Night Shift will wake my patient up due to the vibration, thereby still interrupting his sleep. How it works: Winx (by ApniCure) generates negative pressure in the oral cavity, which draws the soft palate and uvula forward, and stabilizes the tongue position, thus enlarging the upper airway. White: A single night sleep study either in the lab or in the home can easily determine if the Winx device will work in a given patient.
White: The majority of Winx users report that the system is easy to use, clean, and maintain.
New developments in 2014: The FDA approved a lower resistance version of EPAP, Theravent, which is an over-the-counter product indicated only for primary snoring. Williams: The Provent Nasal Cannula is a diagnostic tool to be used with the Provent Sleep Apnea Therapy device during sleep studies, enabling practitioners to confirm product efficacy.
How it works: Stiffens the soft palate, decreasing its flutter and stabilizing the retro-palatal airway. Other considerations: It does not require the removal or destruction of tissue, and is therefore less painful and less risky than traditional palatal stiffening procedures. How it works: Somnoplasty, also known as temperature-controlled radio frequency (TCRF), is a minimally invasive surgical technology that uses radiofrequency current to reduce tissue volume in a precise, targeted manner. How it works: The most common type of oropharyngeal surgery for OSA, UPPP, enlarges the retropalatal upper airway by excising a portion of the posterior soft palate and uvula with trimming and reorientation of the tonsillar pillars. Patients who should NOT try it: Some argue that patients with a BMI of 40 and above should opt for bariatric surgery over oropharyngeal surgery.


New developments in 2014: More and more surgeons are opting to perform a drug-induced sleep endoscopy (DISE) prior to oropharyngeal surgery in order to find out exactly where the blockage is and help determine the responders versus the nonresponders. How it works: Gastric banding, sleeve gastrectomy, and gastric bypass surgery lead to significant weight loss, including lessening the buildup of fat tissue in the upper thorax and neck. Patients who should NOT try it: Patients with severe pulmonary hypertension need a more extensive plan to be prepared for surgery.
How it works: Inspire therapy is an implanted system that senses breathing patterns and delivers mild stimulation to key airway muscles, which keeps the airway open during sleep. Other considerations: Inspire UAS may be used in adult patients 22 years of age and older who have been confirmed to fail or cannot tolerate CPAP and who do not have a complete concentric collapse at the soft palate level. New developments in 2014: In January, results from the STAR trial were published in the New England Journal of Medicine.
We profile the spectrum of FDA-approved therapies, including when to try them, considerations for each, and new developments. For severe OSA patients, only after initial trial of CPAP, oral appliances have been shown to be 50% effective. However, it should be noted that the Vanderveken study published in Thorax found no significant differences between objective and self-reported oral appliance compliance. For patients with an elevated supine apnea index, overall snoring may increase with positional therapy because supine apneas are replaced with snoring. In our study, the number of arousals due to sleep disorder breathing exceeded the number of supine attempts resulting in positional feedback by a factor of 15. Assessment of a neck-based treatment and monitoring device for positional obstructive sleep apnea. However, insurance coverage will increase over time and many patients are willing to pay for Winx out of pocket as they will get a full refund of the console only over the first 30 days of use if Winx is ineffective or not well tolerated.
A multicenter evaluation of oral pressure therapy for the treatment of obstructive sleep apnea. When exhaling, the valve closes and air passing through the nose is directed through two small air channels. The cannula allows transmission of pressure signals from the nose to a pressure transducer of a physiologic recorder with a standard interface designed to attach the nasal cannula to standard pressure transducers, and a custom connection to the Provent Therapy device. A novel nasal expiratory positive airway pressure (EPAP) device for the treatment of obstructive sleep apnea: a randomized controlled trial. For these reasons, the Pillar Procedure may be indicated in any patient with a significant palatal component.
But the soft palate is a significant contributing factor in most patients with OSA, and by combining the Pillar Procedure with other minimally invasive treatments, many patients can achieve significant improvement, without the pain, risk, and inconvenience of surgical intervention.


Efficacy of the Pillar implant in the treatment of snoring and mild-to-moderate obstructive sleep apnea: a meta-analysis.
Favorable anatomy for UPPP includes large tonsils and favorable tongue placement (small base of tongue). The effectiveness has become more consistent with the advent of understanding how the procedures work and with pre- and post-surgery education. Additionally, bariatric surgery and subsequent weight loss provide better treatment options for patients if they are in need of further treatment. Obstructive sleep apnea and pulmonary function in patients with severe obesity before and after bariatric surgery: a randomized clinical trial. A second study showing the capabilities of Night Shift as a screening device accepted for publication.
Use of Night Shift resulted in significant reductions in stage N1 and increased in N2, while REM and sleep efficiency increase and arousals and awakenings were significantly reduced.
This increases the pressure in the airway (expiratory positive airway pressure or EPAP), maintains pressure, and helps to keep the airway open until the start of the next inhalation. Because OSA typically does not result solely from palatal flutter, results are optimized when the Pillar Procedure is combined with other anatomically appropriate treatments.
Weight loss without surgery is much less significant than surgical weight loss, and the medications have contraindications as well. Objective measurement of compliance during oral appliance therapy for sleep-disordered breathing.
Remotely controlled mandibular protrusion during sleep predicts therapeutic success with oral appliances in patients with obstructive sleep apnea. Health outcomes of continuous positive airway pressure versus oral appliance treatment for obstructive sleep apnea: a randomized controlled trial. It is important to tailor the treatment to the individual needs of each patient to promote long-term therapeutic success. And a third option is maxillary mandibular advancement (MMA), in which the upper and lower jaws are surgically moved forward. Night Shift is listed on FSS fee schedule so VA Centers can purchase it at a discount for their patients.
Pillar has been on the market in the United States for over 12 years, and has been shown to be a remarkably safe procedure.



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