Elevated Central and Mixed Apnea Index after Upper Airway Stimulation

2020 ◽  
Vol 162 (5) ◽  
pp. 767-772
Author(s):  
Jena Patel ◽  
Kelly Daniels ◽  
Lauren Bogdan ◽  
Colin Huntley ◽  
Maurits Boon
Keyword(s):  
Care Center ◽  
Univariate Analysis ◽  
Tertiary Care ◽  
Upper Airway ◽  
Retrospective Chart Review ◽  
Comorbid Conditions ◽  
Level Of Evidence ◽  
Upper Airway Stimulation ◽  
Obstructive Sleep ◽  
Post Hoc

Objective Upper airway stimulation (UAS) is used to treat patients with moderate to severe obstructive sleep apnea (OSA). The aim of this study is to report the incidence and potential predictors of elevated central and mixed apnea index (CMAI) after UAS. Study Design Retrospective chart review of patients undergoing UAS. Setting Tertiary care center. Subjects and Methods Included patients underwent UAS for OSA at our institution between 2014 and 2018. Data collected included demographic information, implantation records, and pre- and postoperative polysomnography (PSG) results. CMAI ≥5 was considered elevated. Post hoc univariate analysis was performed to evaluate factors associated with elevated CMAI. Results In total, 141 patients underwent UAS at our institution. This included 94 men and 47 women with a mean age of 61.2 ± 11.0 years and a mean body mass index of 29.1 ± 3.9 kg/m2. Five patients had an elevated CMAI after surgery during UAS titration. Demographics, comorbid conditions, and device settings were not associated with an elevated postoperative CMAI ( P > .05). Conclusion The occurrence of an elevated CMAI after surgery may represent treatment-emergent events. Demographics, comorbid conditions, and UAS device settings were not associated with central and mixed apneic events. Level of Evidence 4

Effect of Gender, Age, and Profound Disease on Upper Airway Stimulation Outcomes

2020 ◽  
Vol 129 (8) ◽  
pp. 772-780
Author(s):  
Jena Patel ◽  
Kelly Daniels ◽  
Lauren Bogdan ◽  
Colin Huntley ◽  
Maurits Boon
Keyword(s):  
Treatment Response ◽  
Initial Treatment ◽  
Care Center ◽  
Tertiary Care ◽  
Upper Airway ◽  
Retrospective Chart Review ◽  
Response To Treatment ◽  
Level Of Evidence ◽  
Upper Airway Stimulation ◽  
Obstructive Sleep

Objective: To evaluate treatment outcomes of upper airway stimulation (UAS) in obstructive sleep apnea (OSA) patients based on patient age, gender, and preoperative disease severity. Methods: Retrospective chart review of patients undergoing UAS from 2014 to 2018 at a tertiary care center. Data collected included demographic information, implantation records, and pre- and postoperative polysomnography (PSG) results. Profound OSA was defined as AHI >65 and age ≥65 was considered advanced age. The primary outcome measured was initial treatment response, defined as a post-operative AHI <20 with a >50% reduction from baseline. Results: 145 patients underwent UAS at our institution including 98 males and 47 females with a mean age of 61.7 ± 11.5 years, mean BMI of 29.1 ± 3.9 kg/m2, and mean preoperative AHI of 34.1 ± 18.2 events/hour. After surgery, patients had a significantly lower mean AHI of 8.6 ± 15.0 events/hour (<0.001). Older patients had a lower initial treatment response rate (78%) when compared to their younger counterparts (94%) ( P = 0.005). Male gender and profound disease status did not significantly impact treatment response rates; young age was the only variable found to predict early treatment response on multivariate analysis ( P = 0.003). Conclusion: Although the overall OSA population showed significant postoperative AHI reduction with UAS, patients age ≥65 years were less likely to have an initial response to treatment, when compared to their younger counterparts. A larger proportion of elderly patients and patients with profound OSA had residual moderate disease (AHI > 15) after UAS. Level of Evidence: 4

The Effect of Lateral Pharyngeal Collapse Patterns on Therapy Response in Upper Airway Stimulation Surgery

2021 ◽  
pp. 000348942098797
Author(s):  
John Flynn ◽  
Christopher Boyd ◽  
Sreeya Yalamanchali ◽  
David Rouse ◽  
Sara Goodwin ◽  
...  
Keyword(s):  
Tertiary Care ◽  
Upper Airway ◽  
Therapy Response ◽  
Apnea Hypopnea Index ◽  
Drug Induced ◽  
Level Of Evidence ◽  
Upper Airway Stimulation ◽  
Effect Change ◽  
Academic Center ◽  
Obstructive Sleep

Objectives: Obstructive sleep apnea (OSA) is characterized by repeated upper airway collapse while sleeping which leads to intermittent hypoxemia. Upper airway stimulation (UAS) is a commonly practiced modality for treating OSA in patients who cannot tolerate, or do not benefit from, positive airway pressure (PAP). The purpose of this study is to identify the effect of lateral pharyngeal collapse patterns on therapy response in UAS. Methods: A retrospective cohort study from a single, tertiary-care academic center was performed. Patients who underwent UAS between October 2016 and July 2019 were identified and analyzed. Drug-induced Sleep Endoscopy (DISE) outcomes between Apnea-Hypopnea Index (AHI) responders and AHI non-responders were compared. Those with complete concentric collapse at the velopharynx were not candidates for UAS. Results: About 95 patients that underwent UAS were included in this study. Pre- to Post-UAS demonstrated significant improvements in Epworth Sleepiness Scale (12.0 vs 4.0, P = .001), AHI (29.8 vs 5.4, P < .001) and minimum oxygen saturation (79% vs 83%, P < .001). No DISE findings significantly predicted AHI response after UAS. Specifically, multiple types of lateral pharyngeal collapse patterns did not adversely effect change in AHI or AHI response rate. Conclusion: Demonstration of lateral pharyngeal collapse on DISE, in the absence of complete concentric velopharyngeal obstruction, does not appear to adversely affect AHI outcomes in UAS patients. Level of Evidence VI

scholarly journals Respiratory Complications following Tonsillectomy/UPPP: Is Step-Down Monitoring Necessary?

2003 ◽  
Vol 82 (8) ◽  
pp. 628-632 ◽  
Author(s):  
Eric M. Gessler ◽  
Peter C. Bondy
Keyword(s):  
Intensive Care Unit ◽  
Intensive Care ◽  
Average Length ◽  
Care Center ◽  
Tertiary Care ◽  
Retrospective Chart Review ◽  
Average Length Of Stay ◽  
Obstructive Sleep ◽  
Respiratory Event ◽  
Step Down

We conducted a study to determine if the risk of airway compromise following tonsillectomy with uvulopalatopharyngoplasty justifies the added cost and inconvenience of step-down monitoring in an intensive care unit. We performed a retrospective chart review of 130 patients with obstructive sleep apnea who had undergone isolated tonsillectomy with uvulopalatopharyngoplasty at our tertiary care center. The average length of stay in the step-down unit was 18 hours. We found that only eight of these patients (6.2%) had a postoperative desaturation level of less than 90%, including three of 12 patients (25%) who had comorbid conditions. No patient had an adverse respiratory event. We conclude that step-down monitoring in an intensive care unit is not necessary, although caution should be exercised in monitoring patients with comorbidities because they appear to be more prone to desaturation. A complete lack of adverse respiratory events has not been reported in previous studies.

Does Insurance Status Impact Delivery of Care with Upper Airway Stimulation for OSA?

2019 ◽  
Vol 129 (2) ◽  
pp. 128-134 ◽  
Author(s):  
Jena Patel ◽  
Michael C. Topf ◽  
Colin Huntley ◽  
Maurits Boon
Keyword(s):  
Private Insurance ◽  
Upper Airway ◽  
Insurance Companies ◽  
Treatment Recommendation ◽  
Drug Induced ◽  
Level Of Evidence ◽  
Upper Airway Stimulation ◽  
Treatment Delays ◽  
Obstructive Sleep ◽  
Medicare Patients

Objective: To understand differences in patient demographics, insurance-related treatment delays, and average waiting times for Medicare and private insurance patients undergoing upper airway stimulation (UAS) for treatment of obstructive sleep apnea (OSA). Methods: Retrospective chart review of all Medicare and private insurance patients undergoing upper airway stimulation (UAS) from 2015 to 2018 at a single academic center. Primary outcomes were insurance-related procedure cancellation rate and time from drug induced sleep endoscopy (DISE) and UAS treatment recommendation to UAS surgery in Medicare versus private insurance patients. Results: In our cohort 207 underwent DISE and were recommended treatment with UAS. Forty-four patients with Medicare and 30 patients with private insurance underwent UAS procedure. Patients with Medicare undergoing UAS were older (67.4 ± 11.1 years) than patients with private insurance (54.9 ± 8.1 years). Medicare patients had a shorter mean wait time of 121.9 ± 75.8 days (range, 15-331 days) from the time of UAS treatment recommendation to UAS surgery when compared to patients with private insurance (201.3 ± 102.2 days; range, 33-477 days). Three patients with Medicare (6.4%) and 8 patients with private insurance (21.1%) were ultimately denied UAS. Conclusion: Medicare patients undergoing UAS have shorter waiting periods, fewer insurance-related treatment delays and may experience fewer procedure cancellations when compared to patients with private insurance. The investigational status of UAS by private insurance companies delays care for patients with OSA. Level of Evidence: 4

scholarly journals Post-approval upper airway stimulation predictors of treatment effectiveness in the ADHERE registry

2018 ◽  
Vol 53 (1) ◽  
pp. 1801405 ◽  
Author(s):  
Clemens Heiser ◽  
Armin Steffen ◽  
Maurits Boon ◽  
Benedikt Hofauer ◽  
Karl Doghramji ◽  
...  
Keyword(s):  
Patient Satisfaction ◽  
Adverse Events ◽  
Treatment Success ◽  
Upper Airway ◽  
The United States ◽  
Final Visit ◽  
Effective Treatment Option ◽  
Upper Airway Stimulation ◽  
Obstructive Sleep ◽  
Post Hoc

Upper airway stimulation (UAS) has been shown to reduce severity of obstructive sleep apnoea. The aim of this study was to identify predictors of UAS therapy response in an international multicentre registry.Patients who underwent UAS implantation in the United States and Germany were enrolled in an observational registry. Data collected included patient characteristics, apnoea/hypopnoea index (AHI), Epworth sleepiness scale (ESS), objective adherence, adverse events and patient satisfaction measures.Post hocunivariate and multiple logistic regression were performed to evaluate factors associated with treatment success.Between October 2016 and January 2018, 508 participants were enrolled from 14 centres. Median AHI was reduced from 34 to 7 events·h−1, median ESS reduced from 12 to 7 from baseline to final visit at 12-month post-implant. Inpost hocanalyses, for each 1-year increase in age, there was a 4% increase in odds of treatment success. For each 1-unit increase in body mass index (BMI), there was 9% reduced odds of treatment success. In the multivariable model, age persisted in serving as statistically significant predictor of treatment success.In a large multicentre international registry, UAS is an effective treatment option with high patient satisfaction and low adverse events. Increasing age and reduced BMI are predictors of treatment response.

456 Esomeprazole Use in Upper Airway Stimulation Patients Associated with Lower Functional Threshold

SLEEP ◽  
2021 ◽  
Vol 44 (Supplement_2) ◽  
pp. A180-A180
Author(s):  
Theodore Klug ◽  
Emily Sagalow ◽  
Ashwin Ananth ◽  
Colin Huntley ◽  
Maurits Boon
Keyword(s):  
Proton Pump Inhibitors ◽  
Proton Pump ◽  
Clinical Benefit ◽  
Tertiary Care ◽  
Care Facility ◽  
Upper Airway ◽  
Upper Airway Stimulation ◽  
Tertiary Care Facility ◽  
Obstructive Sleep ◽  
Threshold Amplitude

Abstract Introduction Proton pump inhibitors (PPIs) are widely used for gastroesophageal reflux disease (GERD) despite possible side effects including increased susceptibility to infections, secondary hypergastrinemia, and incomplete absorption of micronutrients. Upper airway stimulation (UAS) surgery involves delivering an electrical impulse to the distal hypoglossal nerve for the management of obstructive sleep apnea.. The functional threshold (FT) is the minimum stimulation required to achieve bulk tongue motion. The minimum therapeutic amplitude (MTA) is the lowest voltage required to achieve clinical benefit during titration at postoperative attended overnight polysomnography. We sought to analyze the effect of perioperative PPI use upon patients who had undergone upper airway stimulation (UAS) surgery. We hypothesized that the ion transport-related effects of PPIs would impact the amplitude necessary for tongue protrusion (FT) and clinical benefit (MTA). Methods A retrospective chart review was conducted at a single tertiary care facility. Baseline demographic data, medication history, and comorbidities were collected from December 2014 through August 2019 on patients undergoing UAS surgery. Patients that were taking a PPI at the time of surgery and postoperatively were included. Results 167 patients that underwent UAS surgery between 2014 – 2019 were studied. 74 patients were found to be taking a PPI perioperatively. Specifically, 38 patients were found to be on omeprazole, compared to 17 on pantoprazole, 13 on esomeprazole, 4 on lansoprazole, and 2 on rabeprazole. Overall, esomeprazole was a statistically significant predictor (p=0.0359) of a lower functional threshold amplitude: 1.58 mV in controls as compared to 2.09 mV for omeprazole, 2.12 mV for pantoprazole, 2.14 mV for lansoprazole, and 2.7 mV for rabeprazole. Use of PPI, while associated with lower FT voltage, was not a predictor of statistically significant changes in initial UAS minimum therapeutic amplitude settings. Conclusion The functional threshold amplitude for patients taking esomeprazole was significantly different compared to patients not on a PPI. However, the use of PPI overall was not a statistically significant predictor of initial difference in UAS mean therapeutic amplitude settings. Future studies examining tolerance of therapy and voltage changes over time in patients on proton-pump inhibitors are needed. Support (if any):

Predictors for Postoperative Chyle Leak Following Neck Dissection, a Technique-Based Comparison

2021 ◽  
pp. 019459982199381
Author(s):  
Quinn Dunlap ◽  
Matthew Bridges ◽  
Kurt Nelson ◽  
Deanne King ◽  
Brendan C. Stack ◽  
...  
Keyword(s):  
Surgical Technique ◽  
Care Center ◽  
Univariate Analysis ◽  
Tertiary Care ◽  
Retrospective Chart Review ◽  
Severe Malnutrition ◽  
Chyle Leak ◽  
Significant Difference ◽  
Monopolar Electrocautery ◽  
The Impact

Objective Assess the impact of surgical technique used to address level IV on the rate of postoperative chyle leak. Study Design Retrospective chart review. Setting Academic tertiary care center. Methods An analysis of 436 consecutive neck dissections (NDs) in 368 patients was performed by 3 head and neck surgeons between 2014 and 2017. Variation in technique reflects individual approaches to the management of level IV and included suture ligation (SL), monopolar electrocautery (MC), and harmonic scalpel transection (HS). Data points included patient demographics, surgical technique, intraoperative findings, postoperative chyle leaks, and leak management. Correlation between variables was analyzed through χ2 test and Student t test with statistical α set at .05. Results Overall, 12 patients (3.2%) developed chyle leaks postoperatively. Nine of 12 and 3 of 12 presented with left- and right-sided leaks, respectively. Five of 12 leaks occurred following bilateral ND, 5 of 12 following left ND, and 2 of 12 following right ND. Univariate analysis showed a statistically significant difference ( P = .001) favoring SL (1.0%) and MC (1.2%) techniques over the HS technique (8.6%). A statistically significant increase existed in the rate of leak with endocrine vs nonendocrine pathology ( P = .003). Average duration of leak was 13.3 ± 13.5 days. Management included diet modification (n = 11, 91.6%), pressure-dressing placement (n = 7, 58.3%), and octreotide (n = 5, 41.7%). No cases required reoperation, and no mortality or severe malnutrition was observed in this series. Conclusions SL and MC techniques demonstrated superiority over the HS technique in preventative management of chyle leak in level IV, with a significantly higher rate of chyle leak observed in endocrine-related pathology.

Prevalence, Correlates and Management of Hyperglycemia in Diabetic Non-critically Ill Patients at a Tertiary Care Center in Lebanon

2019 ◽  
Vol 15 (2) ◽  
pp. 133-140 ◽  
Author(s):  
Ghada El Khoury ◽  
Hanine Mansour ◽  
Wissam K. Kabbara ◽  
Nibal Chamoun ◽  
Nadim Atallah ◽  
...  
Keyword(s):  
Hospital Stay ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Care Center ◽  
Descriptive Analysis ◽  
Tertiary Care ◽  
Multivariable Analysis ◽  
Length Of Hospital Stay ◽  
Retrospective Chart Review ◽  
Diabetic Patients

Background: Diabetes Mellitus is a chronic metabolic disease that affects 387 million people around the world. Episodes of hyperglycemia in hospitalized diabetic patients are associated with poor clinical outcomes and increased morbidity and mortality. Therefore, prevention of hyperglycemia is critical to decrease the length of hospital stay and to reduce complications and readmissions. Objective: The study aims to examine the prevalence of hyperglycemia and assess the correlates and management of hyperglycemia in diabetic non-critically ill patients. Methods: The study was conducted on the medical wards of a tertiary care teaching hospital in Lebanon. A retrospective chart review was conducted from January 2014 until September 2015. Diabetic patients admitted to Internal Medicine floors were identified. Descriptive analysis was first carried out, followed by a multivariable analysis to study the correlates of hyperglycemia occurrence. Results: A total of 235 medical charts were reviewed. Seventy percent of participants suffered from hyperglycemia during their hospital stay. The identified significant positive correlates for inpatient hyperglycemia, were the use of insulin sliding scale alone (OR=16.438 ± 6.765-39.941, p=0.001) and the low frequency of glucose monitoring. Measuring glucose every 8 hours (OR= 3.583 ± 1.506-8.524, p=0.004) and/or every 12 hours (OR=7.647 ± 0.704-79.231, p=0.0095) was associated with hyperglycemia. The major factor perceived by nurses as a barrier to successful hyperglycemia management was the lack of knowledge about appropriate insulin use (87.5%). Conclusion: Considerable mismanagement of hyperglycemia in diabetic non-critically ill patients exists; indicating a compelling need for the development and implementation of protocol-driven insulin order forms a comprehensive education plan on the appropriate use of insulin.

Comparative Morbidity Profile of Elective vs Therapeutic Neck Dissection

2021 ◽  
pp. 019459982110089
Author(s):  
Quinn Dunlap ◽  
James Reed Gardner ◽  
Amanda Ederle ◽  
Deanne King ◽  
Maya Merriweather ◽  
...  
Keyword(s):  
Neck Dissection ◽  
Surgical Complications ◽  
Chart Review ◽  
Care Center ◽  
Tertiary Care ◽  
Retrospective Chart Review ◽  
Neck Surgery ◽  
Continuous Variables ◽  
Significant Difference ◽  
History Of

Objective Neck dissection (ND) is one of the most commonly performed procedures in head and neck surgery. We sought to compare the morbidity of elective ND (END) versus therapeutic ND (TND). Study Design Retrospective chart review. Setting Academic tertiary care center. Methods Retrospective chart review of 373 NDs performed from January 2015 to December 2018. Patients with radical ND or inadequate chart documentation were excluded. Demographics, clinicopathologic data, complications, and sacrificed structures during ND were retrieved. Statistical analysis was performed with χ2 and analysis of variance for comparison of categorical and continuous variables, respectively, with statistical alpha set a 0.05. Results Patients examined consisted of 224 males (60%) with a mean age of 60 years. TND accounted for 79% (n = 296) as compared with 21% (n = 77) for END. Other than a significantly higher history of radiation (37% vs 7%, P < .001) and endocrine pathology (34% vs 2.6%, P < .001) in the TND group, no significant differences in demographics were found between the therapeutic and elective groups. A significantly higher rate of structure sacrifice and extranodal extension within the TND group was noted to hold in overall and subgroup comparisons. No significant difference in rate of surgical complications was appreciated between groups in overall or subgroup analysis. Conclusion While the significantly higher rate of structure sacrifice among the TND population represents an increased morbidity profile in these patients, no significant difference was found in the rate of surgical complications between groups. The significant difference seen between groups regarding history of radiation and endocrine pathology likely represents selection bias.

Upper Airway Stimulation Therapy for Obstructive Sleep Apnea

2021 ◽  
Keyword(s):  
Obstructive Sleep Apnea ◽  
Sleep Apnea ◽  
Upper Airway ◽  
Novel Therapy ◽  
Upper Airway Stimulation ◽  
Current State ◽  
Obstructive Sleep ◽  
Long Term Follow Up ◽  
Physician Extenders ◽  
Primary Care Practitioners

Upper Airway Stimulation Therapy for Obstructive Sleep Apnea provides the current state of knowledge regarding this novel therapy. It reviews the pathophysiologic basis of sleep apnea and the specific mechanism by which upper airway stimulation provides airway support in this disorder. It also provides practical insights into this therapy related to patient selection, clinical outcomes, surgical technique, long-term follow-up, and adverse events and offers recommendations for those aspiring to develop an upper airway stimulation program. It provides an overview of unique populations and circumstances that may extend the utility of the procedure, and that may provide challenges in management, as well as thoughts on the future of this technology. This textbook is intended for all practitioners who have interest or care for sleep disordered breathing, including sleep medicine physicians, pulmonologists, otolaryngologists, primary care practitioners, as well as physician extenders.

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