Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4421_Библиотеки_им_академика_М_И_Перельмана.pdf
170
W. J. Fillmore
11
. Fig. 11.4 Trauma-related clockwise rotation of the mandible in
a patient who had a nonunion of the right condylar fracture and a
malunion of the left condyle. The patient presented to our clinic with
way obstruction, treatment of etiology must still give
way to surgical correction in order to restore proper
form. Advocates abound for multiple treatment modalities. The most common include:
5 Orthognathic surgery
5 Distraction osteogenesis
5 Autologous reconstruction of the condyle
5 Alloplastic reconstruction of the condyle (total
temporomandibular joint arthroplasty and
reconstruction)
5 Tracheostomy
Traditional orthognathic surgery may be performed
when the condylar resorption has ceased progression [5].
Most often, this will involve a counterclockwise rotation of the maxillomandibular complex with closure of
the anterior open bite with in the mandibular portion of
the surgery. Both bilateral sagittal split osteotomy and
inverted-L osteotomies may accomplish this closure,
depending on the amount of advancement and rotation required. Osseous genioplasty will also often assist
in re- establishing appropriate facial proportions and lip
competence. It is much easier to perform orthognathic
surgery when there is still some remaining condyle to seat,
mandibular retrognathia, TMJ arthralgia, limited range of motion,
and an AHI of 31
but it is still possible after the condyles have completely
resorbed. In addition, there is risk of additional condylar
resorption following orthognathic surgery. Some authors
feel this may be mitigated with medical treatments before
and after surgery [5]. Others also advocate for combined
intraarticular surgery (such as disc repositioning) and
orthognathic surgery.
Distraction osteogenesis is a technique advocated for
correction of malocclusion in patients with condylar
resorption [14]. There is some evidence from animal
studies that distraction techniques were less traumatic to
the condyle than mandibular orthognathic surgery. In
addition, there is other evidence suggesting long-term
stability without relapse. Mandibular distraction may be
accompanied by traditional Le Fort osteotomy as well in
order to optimize jaw position and airway space.
Distraction is a technique that may be considered when
the condyle–fossa relationship is stable and without dysfunction. In cases where there is progressive deterioration of the condyles or signicant TMJ dysfunction, it
may be preferred to consider joint reconstruction.
Condylectomy with costochondral grafting is
another method of restoring posterior face height and
restoring a normal jaw relationship in the setting of con-
Obstructive Sleep Apnea intheSetting ofMandibular Condyle Resorption
171
11
dylar resorption [15]. Both open and endoscopically
assisted approaches have been described with some success, albeit with relatively short-term follow-up and not
always in the setting of concurrent airway obstruction.
a
b
This autogenous graft technique involves donor site
morbidity, but outcomes are stable occlusally and show
good TMJ function. This technique does not rely on
. Fig. 11.5 Radiographic exam from the patient in . Fig. 11.3.
Lateral cephalometric lm showing reduced posterior airway space,
shortened posterior face height, and clockwise mandibular rotation
a. Panoramic radiograph illustrating resorption of the mandibular
condyles b
. Fig. 11.6 Cone Beam Computed Tomography (CBCT) from the patient in . Fig.11.1. Axial and sagittal views clearly show diminished
airway dimensions and may be utilized for volumetric analysis as well
. Fig. 11.7 Three-dimensional model printed for the patient in
. Fig.11.2 with scleroderma. Note the complete absence of the con-
dyle bilaterally and resorption of the nasal bones
172
W. J. Fillmore
11
. Fig. 11.8 Patient-tted (custom) alloplastic total temporoman-
dibular joint reconstruction. This can be used to advance the mandible and correct mandibular rotation and retrusion and may be
employed in conjunction with orthognathic surgery. Prosthesis in the
resolution or stabilization of condylar resorption prior
to or after surgery, and it may also be employed in the
absence of a condyle as well.
Alloplastic total joint reconstruction involves
replacement of both the condyle and fossa components of the temporomandibular joint (. Fig. 11.8).
These may be both patient-tted (custom) and stock
implants. Alloplastic joint replacement eliminates
donor-site morbidity and relapse. Closure of an anterior open bite and advancement of the mandible to
open the airway can also be combined with maxillary orthognathic surgery to achieve optimal jaw
positioning and airway patency [16]. In addition, the
planning stage a. Coronal b and sagittal c views of the nal prosthesis. Lateral cephalometric lm of a patient treated for condylar
resorption and subsequent retrognathia and OSA after orthognathic
surgery in the form of sagittal split osteotomy d
alloplastic joint reconstruction is versatile, in that the
surgeon may not be limited to treatment of idiopathic
condylar resorption; destructive diseases of the joint
including osteoarthritis and inammatory arthropathies are readily addressed [17]. In most cases, this
is the author’s preferred method of reconstruction
and restoration of anatomy in patients with condylar
resorption and OSA together. Drawbacks to alloplastic reconstruction include risk of facial nerve injury,
prosthesis infection, prosthesis failure, or sensitivity
to materials. All of these are very uncommon, and the
prostheses have proven quite durable over long-term
studies [18–20].
Obstructive Sleep Apnea intheSetting ofMandibular Condyle Resorption
173
11
Tracheostomy is a means of establishing a denitive,
secure airway in patients who may be poor candidates
because of failed previous surgery or medical comorbidities. It is, thankfully, rarely required for the patient
with OSA and is usually avoidable in the patient with
condylar resorption when mainstream reconstructive
techniques are utilized.
11.6 Summary
In summary, resorption or destruction of the mandibular condyles may result from a number of different processes. These include various arthridities, trauma, and
idiopathic condylar resorption. If sufcient clockwise
rotation of the mandible and retrognathia combine with
unfavorable soft tissue fullness or laxity in the tongue or
pharynx, obstructive sleep apnea may result. Treatment
of the underlying cause in these cases of OSA may
involve medical management and will typically involve
surgical correction. The goals of surgery are to re-establish posterior face height, establish a normal occlusion,
ensure a functional temporomandibular joint, and sufciently advance or position the maxillomandibular
complex to alleviate obstructive anatomy and physiology. This may be accomplished through multiple means,
including orthognathic surgery, distraction osteogenesis,
condylectomy with costochondral grafting, or alloplastic joint reconstruction.
References
1. Smith CBWP.Surgical management of obstructive sleep apne in
acromegaly with mandibular prognathism and macroglossia: a
treatment dilemma. J Oral Maxillofac Surg. 2012;70(1):207–10.
2. Gunawardena IRS, MacKay S, Woods CM, Choo J, Esterman
A, Carney AS.Submucosal lingualplasty for adult obstructive
sleep apnea. Otolaryngol Head Neck Surg. 2013;148(1):157–65.
3. Tahiri YV-MA, Aldekhayel S, Lee J, Gilardino M.The effectiveness of mandibular distraction in improving airway obstruction in
the pediatric population. Plast Reconstr Surg. 2014;133(3):352e–9e.
4. Ahmad MSE.Temporomandibular joint disorders and orofacial
pain. Dent Clin N Am. 2016;60(1):105–24.
5. Gunson MJAG, Milam SB.Pathophysiology and pharmacologic
control of osseous mandibular condylar resorption. J Oral
Maxillofac Surg. 2012;70(8):1918–34.
6. Wang XDZJ, Gan YH, Zhou YH. Current understanding of
pathogenesis and treatment of TMJ osteoarthritis. J Dent Res.
2015;94(5):666–73.
7. Twilt MMS, Arends LR, ten Cate R, van Suijlekom-Smit
L. Temporomandibular involvement in juvenile idiopathic
arthritis. J Rheumatol. 2004;31(7):1418.
8. Sansare KRM, Mallya SM, Karjodkar F. Management-related
outcomes and radiographic ndings of idiopathic condylar
resorption: a systematic review. Int J Oral Maxillofaci Surg.
2015;44(2):209–16.
9. Arvidsson LZSH, FlatøB LTA.Temporomandibular joint ndings in adults with long-standing juvenile idiopathic arthritis:
CT and MR imaging assessment. Radiology. 2010;256(1):191.
10. Budhram ACR, Rusta-Sallehy S, Ioannidis G, Denburg JA,
Adachi JD, Haaland DA.Anti-cyclic citrullinated peptide antibody as a marker of erosive arthritis in patients with systemic
lupus erythematosus: a systematic review and meta-analysis.
Lupus. 2014;23(11):1156–63.
11. Lee DMSP. Clinical utility of the anti-CCP assay in patients
with rheumatic diseases. Ann Rheum Dis. 2003;62(9):870.
12. ME C.Musculoskeletal manifestations of systemic lupus erythematosus. Rheum Dis Clin N Am. 1988;14(1):99.
13. Whiting PFSN, Sterne JA, Harbord R, Burton A, Burke M,
Beynon R, Ben-Shlomo Y, Axford J, Dieppe P.Systematic review:
accuracy of anti-citrullinated Peptide antibodies for diagnosing
rheumatoid arthritis. Ann Intern Med. 2010;152(7):456.
14. Schendel SATJ, Linck DW 3rd. Idiopathic condylar resorption
and micrognathia: the case for distraction osteogenesis. J Oral
Maxillofac Surg. 2007;65(8):1610–6.
15. Troulis MJTF, Papadaki M, Williams WB, Kaban
LB.Condylectomy and costochondral graft reconstruction for
treatment of active idiopathic condylar resorption. J Oral
Maxillofac Surg. 2008;66:65–72.
16. Mehra PNM, Chigurupati R.Is alloplastic temporomandibular
joint reconstruction a viable option in the surgical management
of adult patients with idiopathic condylar resorption? J Oral
Maxillofac Surg. 2016;74(10):2044–54.
17. Paul SASS, Issac B, Kumar S. Management of severe sleep
apnea secondary to juvenile arthritis with temporomandibular
joint replacement and mandibular advancement. J Pharm
Bioallied Sci. 2015;7(Suppl 2):S687–90.
18. Wolford LMML, Schneiderman ED, Movahed R, Allen
W.Twenty-year follow-up study on a patient-tted temporomandibular joint prosthesis: the techmedica/TMJ concepts device. J
Oral Maxillofac Surg. 2014;73(5):952–60.
19. Mercuri LGEN, Giobbie-Hurder A.Fourteen-year follow-up of
a patient-tted total temporomandibular joint reconstruction
system. J Oral Maxillofac Surg. 2007;65(6):1140–8.
20. Giannakopoulos HESD, Quinn PD.Biomet microxation temporomandibular joint replacement system: a 3-year follow-up
study of patients treated during 1995 to 2005. J Oral Maxillofac
Surg. 2012;70(4):787–94.
Non-surgical
Management of OSA
Contents
Chapter 12 Positive Airway Pressure for the Treatment
of Obstructive Sleep Apnea–177
Shalini Paruthi
Chapter 13 Oral Appliance Therapy–185
Marie Marklund
Chapter 14 Other Therapies and Emerging Options
for Management of OSA–211
Abbey Dunn and Neeraj Kaplish
175
III
177
Positive Airway Pressure for the
Treatment ofObstructive
Sleep Apnea
ShaliniParuthi
Contents
12.1 Introduction – 178
12.2 Indications for Positive Airway Pressure – 178
12.3 PAP Adherence andCompliance – 178
12.4 Dierence Between CPAP andAPAP? – 178
12
12.5 Mask Options – 179
12.6 Possible Side Eects fromPAP Therapy – 180
12.6.1 Dry Mouth – 180
12.6.2 Tangled Tubing – 181
12.6.3 Condensation – 181
12.6.4 Headgear Problems – 181
12.6.5 Humidier Problems – 181
12.6.6 Ramp – 182
12.6.7 Cleaning Equipment – 182
12.6.8 Skin Irritation – 182
12.6.9 Nasal Congestion – 182
12.6.10 Aerophagia – 182
12.7 Cleaning Equipment – 182
12.7.1 Travel Options – 183
References – 183
© Springer Nature Switzerland AG 2021
K. B. Kim et al. (eds.), Management of Obstructive Sleep Apnea, https://doi.org/10.1007/978-3-030-54146-0_12
178
S. Paruthi
12
12.1 Introduction
Positive Airway Pressure (PAP) therapy is the rst-line
and most effective treatment for obstructive sleep apnea
in adults [1]. Continuous positive airway pressure
(CPAP) has been used for treatment of obstructive sleep
apnea since 1981 [2]. PAP works as a pneumatic splint
that maintains the patency of the upper airway during
sleep. It can also be used to treat other sleep-disordered
breathing such as central sleep apnea, hypoventilation,
and treatment emergent central sleep apnea. PAP therapy comes in a variety of forms: continuous positive airway pressure (CPAP), auto-titrating positive airway
pressure (APAP), Bilevel positive airway pressure(BPAP),
and adaptive servoventilation (ASV).
CPAP machines deliver a constant pressure regardless of whether the person is awake, asleep, inhaling, or
exhaling, and resting in any position. BPAP gives a set
pressure during inhalation, but decreases the pressure
delivered during exhalation. BPAP is typically used in
persons with obstructive sleep apnea in whom CPAP is
ineffective. CPAP may be ineffective in patients due to
the patient requiring higher pressures (CPAP max
=20cmH20, BPAP max 30cm H20/30cmH20) or when a
person is intolerant to CPAP, i.e., having difculty exhaling. It may also be used to treat other sleep-disordered
breathing such as sleep-related hypoventilation by helping create an inspiratory: expiratory gradient to help
ventilate [1].
ASV is typically indicated in patients who have
treatment- emergent central sleep apnea, not resolved by
CPAP, BPAP, BPAP with a backup rate, or in patients
with other forms of central sleep apnea such as periodic
breathing.
12.2 Indications for Positive Airway
Pressure
Recent guidelines from the American Academy of Sleep
Medicine (AASM) recommend that treatment with PAP
be based upon a diagnosis of obstructive sleep apnea
established using objective testing. PAP is recommended
to treat obstructive sleep apnea with patients with excessive daytime sleepiness, impaired sleep-related quality of
life, and comorbid hypertension [1]. Other guidelines,
including many payer policies, suggest PAP treatment
for moderate to severe obstructive sleep apnea
(AHI>15) or mild sleep apnea (AHI 5–15) with symptoms of excessive daytime sleepiness, nonrestorative
sleep, insomnia, neurocognitive dysfunction, or a history of mood disorder, hypertension, or cardiovascular
disease. The clinical guidelines for the manual titration
of PAP will not be covered in this chapter but can be
found in reference [5]. Initiation of PAP can be through
either home APAP trial or an in-lab PAP titration per
the recent AASM Clinical Practice Guideline.
Educational interventions, troubleshooting, and followup in person or through telemedicine are also recommended to improve adherence [1].
12.3 PAP Adherence andCompliance
Though PAP is very effective in treating obstructive
sleep apnea, the main barrier is adherence to therapy.
Adherence with PAP has varying denitions, but one
commonly used (though arbitrary) cutoff is use of PAP
therapy for over 4 hours per a night, 70% of nights.
Objective adherence rates using this denition can range
from 40% to 80% depending on a variety of factors [3].
One factor that predicts improved adherence includes
the patient having subjective sleepiness before therapy.
If patients notice improvement in sleep quality, they are
more likely to use PAP long term as therapy for their
obstructive sleep apnea. One important point, subjective reports of adherence have been shown to be much
higher than the objectively reported usage that is available on most PAP machines [4].
12.4 Dierence Between CPAP andAPAP?
Within CPAP therapy, two modalities exist: xed pressure CPAP or auto-adjusting PAP (APAP). For patients
who are titrated in the lab, several pressure settings can
be evaluated to determine which pressure setting best
treats the patient’s sleep disordered breathing and was
tested in a variety of positions and stages of sleep,
including supine-REM sleep. The pressure setting that
best treats the sleep-disordered breathing (SDB) can
then be used to set the pressure on the CPAP machine
[5]. Some clinicians will choose to order an APAP
machine and set the machine to a narrow range of pressures when the pressure setting that appears to work the
best is known. For example, if the PSG identied a pressure setting of 8cmH20 best treated the patient’s SDB in
supine-REM sleep and 6cmH20 best treated SDB in lateral sleep, the CPAP machine may be set from 6 to
8cmH20. Other providers may use a wider range of settings, such as 4–12cmH20 or rarely 4–20cmH20, to
allow the machine to adjust to a higher setting if needed,
since patients may sleep differently at home than in the
lab, or may have other factors (weight, congestion) that
would create a need for a higher pressure setting in the
future.
Therefore, CPAP has a xed pressure setting and
the machine will always deliver the same constant
Positive Airway Pressure fortheTreatment ofObstructive Sleep Apnea
179
12
amount of air, whether inhaling or exhaling and only at
one pressure setting. On the other hand, APAP is an
auto- adjusting CPAP machine, and the machine will
automatically adjust (based on ow of air through the
mask/tubing) within a range of pressures chosen by the
clinician. Research studies show similar adherence
rates and effectiveness between APAP and CPAP [1, 6].
AASM Clinical Practice Guidelines also state that
either is appropriate as therapy for obstructive sleep
apnea [1].
Due to some payer policies, some patients may be
diagnosed and treated for sleep apnea, without ever setting foot in a sleep lab. In this case, after the home sleep
apnea test conrms the presence of hypopneas and
apneas, the patient is prescribed an auto-adjusting PAP
machine. Care must be taken to thoroughly review the
adherence report that can be downloaded from the APAP
machine within the rst 12 weeks or sooner if needed due
to problems, to determine median pressure [1].
Examples to illustrate the importance of close follow- up: If an APAP machine is set to 4−20cm, and the
adherence report shows the median pressure is typically
6cm of water, with the maximum pressure recorded is
20cm, and the patient is complaining of dry mouth or
leak, the pressure can be reset to a lower range of
4–8cmH20, which will likely reduce the patient opening
their mouth, which was causing oral leak and dry mouth.
Conversely, for a patient with an APAP machine set to
4–20, who consistently has a median pressure of 16cm,
this patient may be spending an inordinate amount of
time at suboptimal pressures while the machine is following its algorithm to get up to the median pressure;
thus, the patient may complain of lack of benet or not
getting enough air pressure, i.e., “air hunger” and difculty tolerating the PAP. This machine could be reset to
14-18cm so the patient may receive a therapeutic pressure soon after turning on the machine.
Depending on the brand of machine and the model,
some machines have smart phone applications (apps)
that can be downloaded and used by patients. The apps
use Bluetooth technology to gather data from the
machine and send to a person’s smartphone or tablet.
During clinical visits, the adherence report generated by
the PAP machine is reviewed by the patient’s medical
providers. Adherence Reports (ARs) provide a substantial amount of information that can be used to improve
the efcacy of CPAP for a person and improve the user
experience. This information is also now able to be
accessed via the internet by the clinician and the durable
medical equipment company. Settings may also be
changed through the same technology.
Adherence reports provide information on adherence, as many insurance providers require users to wear
CPAP for >4hours for >70% of nights during a con-
secutive 30-night period, sometime during the initial
90-day period after receiving PAP therapy, in order for
the insurance provider to continue payment for the
equipment and rell of supplies. Adherence reports also
provide data on machine settings, such as pressure or
pressure range, ramp, pressure relief (different name per
each brand), and leak. The reports can be viewed as 1-,
2-, or 7-page (or longer!) reports, and each presents a
different level of detail.
A signicant amount of details are found in the
7-night extended review, which can provide the clinician
an opportunity to see night-to-night variability and
where problems are occurring, such as if it appears the
person’s mouth is opening, causing intermittent leak, or
the pressure range is so high that the person must use the
ramp feature multiple times a night.
Adherence reports also generate a machine-based
respiratory disturbance index (RDI) or apnea-hypopnea
index, or how many times the machine notes changes in
air ow, which would represent a person having partial
or total blockage of the airway. Clinical consensus is
that ideally, the machine-generated RDI goal is <5
events per hour, although if the patient clinically reports
improvement and the machine-generated RDI is <10, it
may be reasonable to make no further changes [5].
Additionally, each brand of machine may have slightly
different algorithms to help determine this RDI as no
arousal or desaturations are measured. Some reports
will further describe what proportion of respiratory
events are likely obstructive, central, or mixed type. This
can be helpful to determine if a person struggling with
CPAP or having lack of benet may need a change in
pressure or needs to be brought in for an in-lab overnight attended titration or re-titration study to determine if the problem is with the mask, tubing, leak,
pressure setting, or treatment-emergent central sleep
apnea, which requires treatment with a different PAP
modality altogether.
12.5 Mask Options
The mask can “make or break” a patient’s CPAP or
APAP experience! When patients dislike their CPAP,
they are often referring to their mask experience.
Studies suggest the best chance for success is to use a
nasal or nasal pillow-type mask initially. Nasal interfaces also seem to have better data with regard to
effectiveness versus full facemasks [5]. It is believed
that full facemasks can actually put pressure on the
lower jaw, causing the jaw/tongue to move backward
through the night, reducing airway dimensions and
increasing airway resistance [5]. However, some people
are unable to keep their mouth closed despite a chin-
180
S. Paruthi
. Fig. 12.1 Example of a nasal mask . Fig. 12.2 Example of a full face or oronasal mask
12
strap or cannot become comfortable with the nasal or
nasal pillow-type mask. Thus, there are a variety of
full facemasks available as well. Masks should not
leave red marks or indentations on the skin for longer
than a few minutes after being removed in the mornings. Recently, manufacturers have placed a warning
that masks with magnetic clips should not be used in
persons with pacemakers or that the magnetic clip
must stay at least 2inches away from the pacemaker
[7]. Most masks are made of silicone material so they
are hypoallergenic. It is common for patients to
exchange masks or get ret with masks as they are getting used to positive airway pressure. There are several
different styles of masks; however, some unique styles
include cloth masks or memory foam masks. See
. Figs.12.1, 12.2, 12.3, and 12.4.
12.6 Possible Side Eects fromPAP Therapy
12.6.1 Dry Mouth
For people who experience dry mouth by morning time,
it is likely they are opening their mouth at some point
during the night, experiencing oral leak. A chinstrap will
help keep the jaw closed, reduce the ability of the mouth
to open, and thus reduce leak and dry mouth discomfort. Other products to try include mouth moisturizers
(articial saliva) or xylitol tablets.
. Fig. 12.3 Example of a nasal pillow-style mask
Positive Airway Pressure fortheTreatment ofObstructive Sleep Apnea
181
12
. Fig. 12.4 Close-up view of the nasal pillow-style mask
It is also important to treat any nasal symptoms,
such as runny nose or nasal congestion, which may have
caused mouth breathing.
12.6.2 Tangled Tubing
The tubing comes in various lengths, heated or nonheated. Tubing can be ordered in lengths of 6, 8, and 10
feet. PAP tubing holders, either store-bought or homemade, can prevent tangling. For example, some people
run their tubing over their headboard, while others run
their tubing up above their pillow. There are also masks
which the tubing connects on the superior portion of the
mask headgear, thus keeping the tubing away from the
face and body altogether.
. Fig. 12.5 Example of tubing sleeve
12.6.4 Headgear Problems
Headgear comes in a variety of sizes and is typically
designed just for the mask it comes with. However,
sometimes the headgear can be mixed and matched with
masks other than the mask it came with. Most masks
are standard with straps and clips to secure the mask in
place all night despite the person’s sleeping position or
position changes. Some unique styles of headgear
include the Bella Loops headgear, which is compatible
with the Swift FX mask, and includes two straps that
loop around the ears; there are no straps that go behind
the head. Another unique headgear is the soft cap headgear, made mostly of spandex, which covers nearly all
of the posterior surface of the head and snuggly secures
the mask overnight. There are some headgears that have
an extra loop built in, either on the side or the top of the
headgear to help secure the tubing, again to decrease the
person becoming entangled. Patients are requested to
hand-wash and air-dry the headgear every 2–4weeks to
help the headgear maintain its shape and elasticity.
12.6.3 Condensation
Heated tubing may help decrease condensation, also
commonly referred to as “rain-out”, within the tubing
when there is signicant mismatch in the bedroom air
temperature (much cooler) and the temperature of the
air inside the tubing (much warmer). Tubing sleeves or
tubing covers are also available. See . Fig.12.5.
12.6.5 Humidier Problems
Humidiers have become standard on most machines.
They can be adjusted from OFF (or zero) up to the
highest setting offered by each brand. There is a hot
metal plate on the bottom of the water container that
heats up proportional to the setting selected in the settings menu. It is recommended that for regular use, dis-