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
182
S. Paruthi
tilled water is used nightly and the excess dumped out
each morning, with the humidier container allowed to
air dry between uses. The benets of distilled water
include that it is mineral- free and microorganism-free
due to the process of distilling water. Water is boiled,
and only the evaporation is collected to create distilled
water. Due to presence of microorganisms, it is not
advised to use tap water or well water on a daily basis, as
the air in the PAP machines pick up moisture from the
humidier chamber.
12.6.6 Ramp
The ramp feature is a patient-comfort feature. When the
machine is started, or anytime during the night, with the
push of a button, the air pressure can be “reset” and
restarted at a previously lower set pressure. For example,
for a person on an APAP machine with a range of
8–10cmH20 and a ramp start pressure of 4cmH20, each
time the person desires, s/he can push the ramp button
and restart the pressure at 4cmH20. This setting allows
the pressure to slowly increase to the goal pressure setting, over a prespecied time period. Ramp time periods
can be set from 5 to 45minutes on most machines.
12.6.9 Nasal Congestion
Some patients will experience nasal congestion, while
others will experience clearing of their nasal congestion after starting PAP therapy. Over-the-counter
saline- based solutions are available to help with nasal
congestion or dryness, and can be applied inside the
nostril prior to using PAP. An alternative is petroleum jelly.
Additionally for persons with signicant “runny”
nose, prescription ipratropium bromide spray can be
sprayed inside the nostrils. For people with “stuffy”
nose, a nasal corticosteroid can be considered. Nasal
saline rinse or squeeze bottles may be helpful. Treatment
for seasonal allergies is also recommended with antihistamines or leukotriene inhibitors.
12.6.10 Aerophagia
Some patients will describe increased belching, burping, or passing gas after waking up after starting PAP
therapy due to swallowing air. Treatment of this aerophagia is to decrease the machine pressure setting or
pressure range until this no longer occurs, yet maintains a low RDI.
12
12.6.7 Cleaning Equipment
12.6.8 Skin Irritation
Skin care is an important consideration for PAP users.
The mask t should be snug, not too tight, and not
too loose. Masks should t comfortably, without leaving lasting red marks or indentations after 7hours of
continuous use. It is normal to have some indentations for a few minutes after removing the mask. For
patients who get red sores or skin irritation, petroleum jelly or zinc oxide preparations can help soothe
and heal the skin.
Sometimes the mask needs to be exchanged for a different style altogether. Sometimes people alternate different mask styles so that the face does not have constant
pressure in the same place every night. Wraps are small
cloths with Velcro designed to wrap around the PAP
straps to cushion the skin to decrease the appearance of
indentations. For patient who use the nasal pillow-style
masks and have chang to the skin between their nostrils, they may need to consider switching masks.
12.7 Cleaning Equipment
Cleaning the equipment is vital to equipment longevity.
The mask cushion, which can be dissembled from
the headgear, should be washed with a gentle dish soap,
wiped, or sanitized daily. Baby wipes or CPAPdesignated wipes can ease the burden of daily cleaning
to remove the natural oils, sweat, and nasal drainage
that can accumulate on the mask cushion. Alcoholcontaining or bleach-containing wipes should not be
used. The headgear and other plastic parts of the mask
should be hand-washed at least weekly. The tubing and
humidier chamber should be cleaned weekly with soap
and water. After a night of use, any water remaining in
the humidier container should be emptied daily in the
morning and the water container allowed to air-dry.
Filters should be changed as specied in the user manual.
Additionally, for intermittent, more thorough
antimicrobial cleaning, the equipment may be soaked
in a vinegar mixture, typically 1 part vinegar to 5
parts water for about 15minutes. This can be consid-
Positive Airway Pressure fortheTreatment ofObstructive Sleep Apnea
183
12
ered every few months or particularly after a person
has used their PAP equipment while also suffering
from an upper respiratory infection. Several chemical
sanitizers or ultraviolet light sanitizer devices are
available on the market for purchase to clean the
machines; however, there are no data to suggest that
these are more benecial over traditional soap and
water cleaning.
12.7.1 Travel Options
Travel CPAP and APAP machines are available from
durable medical equipment suppliers. The machines
can be used plugged in at night or used with an additional battery attachment. Optional humidiers or
humidifying mechanisms may be available. However,
not every mask ts with every travel machine. The tubing is typically less wide and less heavy, so it pulls on
the mask less. Heated tubing is currently not available.
Currently, some travel machines can provide adherence
reports.
References
1. Patil SP, Ayappa IA, Caples SM, Kimoff RJ, Patel SR, Harrod
CG.Treatment of adult obstructive sleep apnea with positive
airway pressure: an American Academy of clinical practice
guideline. J Clin Sleep Med. 2019;15(2):335–43.
2. Sullivan C, Issa F, Berthon-Jones M, etal. Reversal of obstruc-
tive sleep apnea by continuous positive airway pressure applied
through the nares. Lancet. 1981;1:862–5.
3. McArdle N, Devereux G, Heidarnejad H, etal. Long-term use
of CPAP therapy for sleep apnea/hypopnea syndrome. Am J
Respir Crit Care Med. 1999;159(4):1108–14.
4. Kribbs NB, Pack AI, Kline LR, etal. Objective measurement of
patterns of nasal CPAP use by patients with obstructive sleep
apnea. Am Rev Respir Dis. 1993;147(4):887–95.
5. Kushida A, Chediak RB, etal. Clinical guidelines for the manual
titration of positive airway pressure in patients with obstructive
sleep apnea. J Clin Sleep Med. 2008;4(2):157–71.
6. Rosen CL, Auckley D, Benca R, etal. A multisite randomized
trial of portable sleep studies and positive airway pressure
autotitration versus laboratory-based polysomnography for the
diagnosis and treatment of obstructive sleep apnea: the
HomePAP study. Sleep. 2012;35(6):757–6.
7. Schwartz Y, Wasserlauf J, Sahakian AV, Knight B.Inappropriate
activation of pacemaker magnet response by CPAP masks.
Pacing Clin Electrophysiol. 2019;42(8):1158–61.
Oral Appliance Therapy
Marie Marklund
Contents
13.1 Introduction – 187
13.2 Terminology – 188
13.3 Devices That Hold theMandible Anteriorly—OAM – 188
13.3.1 Mechanism ofAction – 188
13.3.2 Device Designs – 188
13.4 Methodology – 190
13.5 Short-Term Eects onAHI – 190
185
13
13.6 Denitions ofTreatment Success – 190
13.7 Factors Related totheEcacy ofOAM – 191
13.7.1 Importance ofMandibular Repositioning – 191
13.7.2 Device Design – 191
13.7.3 Determining theOptimal Mandibular Position andFind Responders
toOAM Therapy – 192
13.7.4 Pharyngeal Anatomy andPhysiology – 193
13.7.5 Non-anatomical Traits – 193
13.7.6 Disease Severity – 193
13.7.7 Supine Dependency – 193
13.7.8 Anthropometric Variables fromtheClinical Examinations – 194
13.8 Eects ofOAs onSnoring andthe Upper Airway Resistance
Syndrome – 194
13.9 Symptomatic Eects ofOAs – 195
13.10 Cardiovascular Eects – 196
13.11 Side Eects – 196
13.11.1 Forces fromtheDevice – 196
13.11.2 Short-Term Side Eects – 196
13.11.3 Methods toAvoid Initial Side Eects – 197
13.11.4 Longer Term Side Eects – 197
13.11.5 Changes inDental Occlusion – 197
© 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_13
13.11.6 Bite Changes inRelation toInitial Bite Characteristics – 199
13.11.7 Bite Changes inRelation toMandibular Repositioning – 199
13.11.8 Device Design andPossibilities toPrevent Bite Changes – 199
13.11.9 Comparison ofBite Changes Between PAP andOAM – 199
13.12 Adherence andMean Disease Alleviation – 200
13.12.1 Measurement ofAdherence – 200
13.12.2 Denitions ofAdherence – 200
13.12.3 Adherence – 200
13.12.4 Mean Disease Alleviation – 200
13.12.5 Reasons forOA Non-adherence withOAM – 200
13.13 Long-Term Outcomes – 201
13.14 OAM in Relation to Other OSA Treatments – 202
13.14.1 OAM Compared with Positional Therapy – 202
13.14.2 OAM Combined with Positional Therapy – 202
13.14.3 OAM Combined with PAP – 202
13.15 OAs asSecond-Line Treatment – 202
13.16 Guidelines – 202
13.17 Summary ofOAM – 203
13.18 Devices That Hold theTongue Forward—OAT – 203
13.18.1 Eects – 203
13.18.2 Side Eects – 203
13.18.3 Summary ofOAT – 203
References – 204
Oral Appliance Therapy
187
13
13.1 Introduction
Oral appliances (OAs) aim to increase the upper airway size, facilitate breathing during the night, and
reduce obstructive sleep apnea (OSA) and snoring
(. Fig.13.1a, b). There are two subgroups of OAs: the
mandibular advancement device (OAM) (. Fig. 13.2)
and the tongue- retaining device (OAT) (. Fig. 13.3).
OAM is attached to the teeth and holds the mandible
forward during sleep. This treatment has the highest
level of evidence among non-PAP therapies [1–4]. OAT
aims to hold the tongue forward into an anterior bulb
by suction and can be used irrespective of the presence
a
of teeth. Both devices reduce sleep apneas, but OA
is
M
better tolerated and has been much more studied.
This chapter primarily describes OAM treatment;
the effects, the side effects, and the longer term outcomes. The efcacy of OA is more variable than that
of PAP, since its mechanism of action depends on a
number of factors such as the degree of mandibular
or tongue advancement and OSA endotype [5]. OAM
can be used solely or in combination with other sleep
apnea treatments such as positive airway pressure (PAP)
or positional therapy, when the efcacy of OA alone is
insufcient. The adverse effects of OAs are generally
mild, but in the longer term, there are risks of tooth
b
. Fig. 13.1 a Illustration of the mechanism of the oral appliance. b Photo without (left) and with (right) the oral appliance showing the
widening of the upper airway with the appliance in place compared to without it
13
188
M. Marklund
. Fig. 13.2 Schematic illustration of the OA
. Fig. 13.3 Schematic illustration of the OA
M
T
movements from the forces of these devices. OA treatment must be continuously followed-up regarding efcacy, side effects, and adherence.
13.3 Devices That Hold theMandible
Anteriorly—OA
13.3.1 Mechanism ofAction
M
OAM repositions the lower jaw anteriorly and slightly
opened in order to increase the upper airway volume
and reduce the pharyngeal collapsibility (. Fig.13.1a)
[7–10]. The upper airway is enlarged, particularly
in its lateral dimension at the velopharyngeal level
(. Fig. 13.1b), and the tongue is displaced anteriorly
[8, 9, 11, 12]. The mechanism of action of OAM is variably efcient depending on a number of factors such as
OSA pathogenesis and OA design. To various degrees,
OSA patients may have some degree of anatomical compromise in their upper airway, a reduced dilator muscular activity, an increased pharyngeal collapsibility, an
overly sensitive ventilatory control system (high loop
gain), or a low arousal threshold [13]. OA
compensates
M
for individual deciencies in upper airway anatomy.
Non- anatomical traits such as a high loop gain or a low
arousal threshold are unchanged by OAM [14]. Patients
with mild OSA are generally better suited for the mechanism of OAM compared with patients with more severe
OSA, since mild OSA patients often have less collapsible
airways [13, 14]. Pharynx has also been found to widen
more, along its whole length in mild OSA patients, compared with patients with more severe disease [15].
In summary, the mechanism of action of OAM is less
effective compared with PAP that increases the airow in
the upper airway in relation to the needs of each patient.
This means that the indications of OAM are more difcult to assess and that the treatment has to be more rigorously controlled and followed up compared with PAP.
13.2 Terminology
OA is a generic term for devices that are inserted into
the mouth in order to modify the position of the tongue
and other structures to reduce snoring and sleep apnea
[6]. The oral appliance that holds the mandible anteriorly, the OA
is also termed “mandibular advance-
M
ment device (MAD),” “mandibular advancement splint
(MAS),” “mandibular repositioning appliance (MRA),”
“unterkieferprotusionsschiene (UPS),” and “orthèses
d’avancée mandibulaire (OAM).” A device that holds
the tongue forward, OAT, is named “tongue-retaining
device (TRD)” or “tongue-stabilizing device (TSD).”
There are combinations of OAM and OAT including both
mechanisms. Most commonly, the term OA is used synonymously for OAM, since this type of OA has become
overwhelmingly most common.
13.3.2 Device Designs
There are many various designs of OAM (. Fig.13.4a–
h), and they may be subdivided in various ways. There
are custom-made devices and prefabricated ones. The
evidence for the efcacy of OA
therapy is primar-
M
ily based on the results of custom-made devices. The
knowledge about custom-made devices will therefore
constitute the major part of this chapter.
OAMs have various types of adjustment mechanisms between the jaws in order to facilitate changes in
jaw positioning and improve the efcacy and tolerability of the device [16–19]. The adjustment mechanism
can be located either laterally on each side of the jaws
(. Fig. 13.4a–d) or in the midline (. Fig. 13.4e–f).
These mechanisms are primarily intended for anteriorposterior adjustments of the lower jaw during the
titration procedure when the optimal jaw position is
a
b
c
e
gh
Oral Appliance Therapy
189
d
13
f
. Fig. 13.4 a–g Various designs of adjustable OAM. The adjust-
ment mechanism of the device may be located laterally a–d or in the
midline e–f. Some appliances allow mouth opening a–e. Elastic
determined. During use, the jaws can be xed rmly
together by the mechanism (. Fig.13.4f). More or less
mouth opening can also be allowed with other types of
mechanisms (. Fig.13.4a–e). This mouth opening can
be prevented by the use of elastic bands (. Fig.13.4g).
bands can be applied in different ways in order to hold the jaws
together and certify the degree of advancement g. A new device
introduces a combination of lateral and midline mechanism h
Lateral adjustment or some movement in the lateral
dimension is possible in several designs. The earliest
types of OAM were made in one piece and lacked this
adjustment mechanism. Titration of mandibular positioning was more difcult, since it required new con-
190
M. Marklund
13
struction bites and help from a dental technician to
remake the device with the lower jaw in a new position.
An opening within the appliance to allow mouth
breathing might be important for many patients, since
nocturnal nasal obstruction is reported by one third
of sleep apnea patients [20]. Still, it is essential that the
appliance allows the lips to close in order to primarily
promote nasal breathing.
In summary, custom-made oral appliances that
allow titration of the lower jaw position are recommended. These appliances are most commonly used in
clinical practice, since the adjustment mechanism is considered to be important for the efcacy and tolerance of
the device.
13.4 Methodology
Good oral health is essential for treatment success with
OAM and it is therefore important with a complete odontological investigation including dental occlusion, jaw
movements, and the temporomandibular joint. Patients
with poor oral health should be treated for these conditions before OAM therapy is initiated. Existing odontological diseases will increase the risk of further impaired
oral health, side effects, and a poor treatment outcome.
If the teeth are unsuited to hold the lower jaw forward,
the mechanism of the device is also jeopardized.
OAM therapy starts with impressions or intraoral
scanning of the teeth. Thereafter, a bite registration
in an advanced mandibular position is taken in wax
or other material. This registration is advised to be
taken with the mandible advanced straight forward
and approximately 50% forward of maximum protrusive capacity or 4–6mm compared with centric relation. In patients with a poor protrusive capacity, some
increase in protrusive capacity might be expected during the rst months’ of treatment [21]. A bite fork or
a steel sliding caliper can be used to help the patient
nd this position. After fabrication and adaptation
of the device to the teeth of the individual patient,
a test period starts with acclimatization and titration
of the lower jaw forward. This means that the lower
jaw is continuously advanced in steps of in between
0.1 and 1mm until an effective mandibular positioning is identied. A renewed sleep apnea recording has
to be performed in order to verify the treatment outcome of OA
on breathing stops and oxygenation.
M
Such recordings must be repeated until an effective
mandibular position is found, particularly in patients
with moderate to severe disease or comorbidities.
Intermediate testing during the titration procedure
can be performed at the dentist’s ofce, depending
on the health-care system in each country. The nal
decision about the efcacy of the device in relation to
the individual patient’s health is made by the referring
sleep physician. In the future, this titration procedure
may be simplied by an overnight testing of the optimal mandibular positioning at home [22] or by the use
of auto adapting devices [23].
In summary, OAM therapy requires good oral health,
a time for adaptation and titration of an optimal jaw
positioning, and conrmation of the efcacy of the
treatment in renewed sleep apnea recordings.
13.5 Short-Term Eects onAHI
OAM reduces AHI effectively compared with placebo
interventions or untreated controls [24–37] (. Fig.13.5).
PAP is more effective than OAM in reducing AHI, according to studies comprising patients with varying disease
severity [24, 25, 32, 38–45] (. Fig. 13.6). Among the
mildest OSA patients, this difference becomes smaller or
is levelled out [3, 24, 42, 46]. The nightly oxygenation is
improved with OA
[2, 3], but PAP restores the nightly
M
oxygenation even further [2].
13.6 Denitions ofTreatment Success
There are several denitions of treatment success for
OAM therapy [47]. These are based either on strict cutoff points, such as an AHI of below 5 or 10 or a percentage cut-off, usually a 50% or more reduction in
AHI.Combinations of criteria are also used, such as an
AHI <5 + the resolution of symptoms or AHI <5 or
10+50% or more reduction in AHI.The last criterion
assures a sufcient AHI reduction also among the mildest cases.
Complete responders are dened by an AHI <5,
often with an additional requirement of 50% reduction
or more in AHI, non-responders have less than 50%
reduction in AHI and a treated AHI of above a specic
level, such as 20, and partial responders lie in between
[28, 29, 41–43].
The proportion of patients who receive complete success with an AHI<5 sometimes with an additional requirement of ≥50% reduction in AHI varies in between 10%
and 57% in randomized controlled trials including patients
of varying disease severity [26–29, 34–36, 38, 41–43]. The
reason for this large variability in response to OA
therapy
M
depends on factors such as disease severity, patients’ phenotype, denitions of sleep-disordered breathing events,
and methodology including device design.
In summary, there is a high level of evidence of a
satisfactory AHI reduction by OA
. The variability
M
in treatment response means that PAP will represent a
more efcient alternative, particularly among the more
severe OSA patients.
50
AHI or RDI
Hans et al. 1997 Petri et al. 2008 Gagnadoux et al. 2017
Oral Appliance Therapy
45
40
35
30
25
20
15
10
191
13
5
0
Baseline Placebo Baseline OA
Durán-Cantolla et al. 2015 Marklund et al. 2015 Barnes et al. 2004 Mehta et al. 2001
Gotsopoulos et al. 2002 Naismith et al. 2005 Johnston et al. 2002 Blanco et al. 2005
. Fig. 13.5 Effect of OAM compared with baseline and placebo
13.7 Factors Related totheEcacy ofOA
13.7.1 Importance ofMandibular
Repositioning
A larger advancement of the mandible will generally
produce a higher efcacy of OAM [7, 48], but there is no
exact linear relationship between mandibular advancement and treatment success [49, 50]. In addition, the
needed advancement might be inuenced by disease
severity or other individual factors [51]. Despite this,
an insufcient capacity of the patient to move the mandible forward to some degree will limit the possibilities
to receive an optimal treatment outcome with OAM
therapy. A device that is produced with the mandible
extensively opened is likely to produce a poorer result
[52] compared with a device that is constructed within a
more limited range of mandibular opening [53, 54]. Too
wide openings over a centimeter have also been related
to discomfort for the patient [54].
13.7.2 Device Design
M
Comparison between different devices regarding their
efcacy in reducing AHI have been made in 13 randomized controlled trials [37, 54–65] and four nonrandomized studies [66–69]. Nine of the 13 randomized
studies compared various custom-made designs [54–58,
60–62, 64, 65] and showed no or only small differences.
Two studies compared a custom-made device versus a
prefabricated one [59, 63] and both favored the custommade designs. Complete treatment response was found
in 49% [63] and 64% [59] of the patients when they
used a custom-made design and in only 17% and 24%,
respectively, when they were treated with a prefabricated
device. This result is further supported by results of a
non-randomized study [66]. The prefabricated device
was also unreliable as test device to nd responders
to OAM according to one study [63]. In addition, the
results from a large study including various degrees of
customized devices showed fairly small AHI reductions
192
50
eC
AHI
Gagnadoux et al. 2009 Hoekema et al. 2008
M. Marklund
45
40
35
30
25
20
15
10
13
5
0
Baseline OA Baselin
Randerath et al. 2002 Ferguson et al. 1996 Lam et al. 2007 Barnes et al. 2004
Tan et al. 2002 Ferguson et al. 1997 Phillips et al. 2013 Engleman et al. 2002
. Fig. 13.6 Effect of OAM compared with baseline and PAP
by non- customized designs, although they did not differ signicantly [37]. The retention of non-customized
designs might be one explanation to their poor efcacy
[70], although the properties of the materials in these
devices are improving [69, 71].
Adjustable devices where one of them xate the lower
jaw to the upper jaw and the other one allowed mouth
opening were compared in seven randomized studies
[55–58, 62, 64, 65]. Six of them favored the xed design,
four signicantly [55, 58, 62, 64]. Further support for
these ndings is presented in one non- randomized study
[67] and two studies comparing the inuence of elastic
bands that hold the jaws together in devices that allows
mouth opening [61, 68]. Based on these studies as well
as some observational ones [18, 19, 67, 72], adjustable,
custom-made devices that xate the lower jaw to the
upper are most effective.
PAP
13.7.3 Determining theOptimal
Mandibular Position andFind
Responders toOA
New technology can be used to nd the optimal mandibular position and predict which patients that are likely to
respond to the treatment. A feedback- controlled mandibular positioner has been developed and tested during
un-attended in-home conditions [22]. This method is a
further step forward and a cheaper alternative compared
with the previous system using a remotely controlled
mandibuilar advancement device during an attended
in-hospital testing night [73–75]. The developed testing
method produced a high potential of predicting treatment success dened as an oxygen desaturation index
(ODI) of less than 10 with a sensitivity 85% and a speci-
Therapy
M