Phenotypic Approaches to Obstructive Sleep Apnea - New Pathways for Targeted Therapy

A special issue of Medicina (ISSN 1648-9144). This special issue belongs to the section "Pulmonary".

Deadline for manuscript submissions: closed (31 July 2021) | Viewed by 20015

Special Issue Editors

Special Issue Information

Dear Colleagues,

The pathophysiology of obstructive sleep apnea syndrome (OSA) is heterogenous with various contributing factors. Four contributing phenotypes recently identified are airway collapsibility or impaired anatomy, poor pharyngeal muscle responsiveness, a low arousal threshold, and a high loop gain, interacting alone or together, resulting in different phenotypic traits of OSA.

This Special Issue will focus on OSA pathophysiology and new emerging tools for identification of anatomic and non-anatomic phenotypic traits to enable a targeted treatment approach. In addition, airway limitations (inspiratory flow limitations, negative effort dependence) predict the upper airway (UA) anatomical abnormality and collapsibility with potential cardiovascular risks in pregnant woman and in upper airway resistance syndrome.

OSA treatment options are mainly focused to improve the impaired UA anatomy. Continuous positive airway pressure (CPAP) represents the first-line therapy, but 50% of CPAP users are non-adherent. UA surgery includes a broad list of procedures, providing long-term outcomes in selected patients, although the complete resolution of the apneas is not often obtained.

Consequently, the need to identify key phenotypic traits to employ a targeted treatment in a precision model approach is increasing. We discuss the success of non-CPAP treatments including surgery, mandibular advancement devices, and hypoglossal nerve stimulations in moderate OSA when employed in the targeted phenotypic approach. Finally, we report preliminary results for drug therapy and myofunctional therapy in the treatment of OSA.

Dr. Andrea de Vito
Dr. Venkata Koka
Guest Editors

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Keywords

  • obstructive sleep apnea syndrome
  • critical pressure
  • loop gain
  • arousal threshold
  • muscular impairment
  • airflow limitations
  • continuous positive airway pressure
  • upper airway surgery
  • barbed pharyngoplasty
  • upper airway transoral robotic surgery
  • hypoglossal nerve stimulation
  • mandibular advancement devices

Published Papers (3 papers)

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11 pages, 533 KiB  
Article
Diagnosis of Obstructive Sleep Apnea in Patients with Allergic and Non-Allergic Rhinitis
by Annalisa Pace, Giannicola Iannella, Valeria Rossetti, Irene Claudia Visconti, Giampiero Gulotta, Carlo Cavaliere, Andrea De Vito, Antonino Maniaci, Salvatore Cocuzza, Giuseppe Magliulo and Andrea Ciofalo
Medicina 2020, 56(9), 454; https://0-doi-org.brum.beds.ac.uk/10.3390/medicina56090454 - 08 Sep 2020
Cited by 30 | Viewed by 5604
Abstract
Background and objectives: Rhinitis could be considered a risk factor for obstructive sleep apnea (OSA). Studies were conducted to evaluate the relation between OSA and Allergic rhinitis (AR). Non-allergic rhinitis with eosinophilia syndrome (NARES) is a condition with a symptomatology apparently similar [...] Read more.
Background and objectives: Rhinitis could be considered a risk factor for obstructive sleep apnea (OSA). Studies were conducted to evaluate the relation between OSA and Allergic rhinitis (AR). Non-allergic rhinitis with eosinophilia syndrome (NARES) is a condition with a symptomatology apparently similar to AR. The aim of this study was to evaluate the different presence of OSA in patients suffering from NARES and AR. Materials and Methods: Sixty patients were enrolled and subdivided into NARES, AR and control groups. NARES and AR diagnosis were performed using ARIA (Allergic Rhinitis and its Impact on Asthma) protocol. All patients were screened for OSA with home sleep apnea testing (HSAT) exam analyzing AHI (Apnea Hypopnea Index) values. Results: Results showed that 60% of patients affected by NARES presented OSA. On the contrary, altered AHI was found only in 35% of patients affected by AR and in 10% of patients belonging to the control group. Conclusions: In conclusion, data showed that there was an increased risk of OSA in NARES patients respect to AR patients and healthy patients. Full article
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14 pages, 340 KiB  
Review
OSA Upper Airways Surgery: A Targeted Approach
by Andrea De Vito, B. Tucker Woodson, Venkata Koka, Giovanni Cammaroto, Giannicola Iannella, Marcello Bosi, Stefano Pelucchi, Giulio Romano Filograna-Pignatelli, Pierre El Chater and Claudio Vicini
Medicina 2021, 57(7), 690; https://0-doi-org.brum.beds.ac.uk/10.3390/medicina57070690 - 06 Jul 2021
Cited by 14 | Viewed by 3289
Abstract
Obstructive sleep apnea syndrome (OSA) is a multi-factorial disorder, with quite complex endotypes, consisting of anatomical and non-anatomical pathophysiological factors. Continuous positive airway pressure (CPAP) is recognized as the first-line standard treatment for OSA, whereas upper airway (UA) surgery is often recommended for [...] Read more.
Obstructive sleep apnea syndrome (OSA) is a multi-factorial disorder, with quite complex endotypes, consisting of anatomical and non-anatomical pathophysiological factors. Continuous positive airway pressure (CPAP) is recognized as the first-line standard treatment for OSA, whereas upper airway (UA) surgery is often recommended for treating OSA patients who have refused or cannot tolerate CPAP. The main results achievable by the surgery are UA expansion, and/or stabilization, and/or removal of the obstructive tissue to different UA levels. The site and pattern of UA collapse identification is of upmost importance in selecting the customized surgical procedure to perform, as well as the identification of the relation between anatomical and non-anatomical factors in each patient. Medical history, sleep studies, clinical examination, UA endoscopy in awake and drug-induced sedation, and imaging help the otorhinolaryngologist in selecting the surgical candidate, identifying OSA patients with mild UA collapsibility or tissue UA obstruction, which allow achievement of the best surgical outcomes. Literature data reported that the latest palatal surgical procedures, such as expansion sphincter palatoplasty or barbed reposition palatoplasty, which achieve soft palatal and lateral pharyngeal wall remodeling and stiffening, improved the Apnea Hypopnea Index, but the outcome analyses are still limited by methodological bias and the limited number of patients’ in each study. Otherwise, the latest literature data have also demonstrated the role of UA surgery in the improvement of non-anatomical factors, confirming that a multidisciplinary and multimodality diagnostic and therapeutical approach to OSA patients could allow the best selection of customized treatment options and outcomes. Full article
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Review
Orofacial Myofunctional Therapy in Obstructive Sleep Apnea Syndrome: A Pathophysiological Perspective
by Venkata Koka, Andrea De Vito, Gabriel Roisman, Michel Petitjean, Giulio Romano Filograna Pignatelli, Davide Padovani and Winfried Randerath
Medicina 2021, 57(4), 323; https://0-doi-org.brum.beds.ac.uk/10.3390/medicina57040323 - 01 Apr 2021
Cited by 28 | Viewed by 10058
Abstract
Obstructive sleep apnea (OSA) syndrome is a multi-factorial disorder. Recently identified pathophysiological contributing factors include airway collapsibility, poor pharyngeal muscle responsiveness, a low arousal threshold, and a high loop gain. Understanding the pathophysiology is of pivotal importance to select the most effective treatment [...] Read more.
Obstructive sleep apnea (OSA) syndrome is a multi-factorial disorder. Recently identified pathophysiological contributing factors include airway collapsibility, poor pharyngeal muscle responsiveness, a low arousal threshold, and a high loop gain. Understanding the pathophysiology is of pivotal importance to select the most effective treatment option. It is well documented that conventional treatments (continuous positive airway pressure (CPAP), upper airway surgery, and dental appliance) may not always be successful in the presence of non-anatomical traits, especially in mild to moderate OSA. Orofacial myofunctional therapy (OMT) consists of isotonic and isometric exercises targeted to oral and oropharyngeal structures, with the aim of increasing muscle tone, endurance, and coordinated movements of pharyngeal and peripharyngeal muscles. Recent studies have demonstrated the efficacy of OMT in reducing snoring, apnea–hypopnea index, and daytime sleepiness, and improving oxygen saturations and sleep quality. Myofunctional therapy helps to reposition the tongue, improve nasal breathing, and increase muscle tone in pediatric and adult OSA patients. Studies have shown that OMT prevents residual OSA in children after adenotonsillectomy and helps adherence in CPAP-treated OSA patients. Randomized multi-institutional studies will be necessary in the future to determine the effectiveness of OMT in a single or combined modality targeted approach in the treatment of OSA. In this narrative review, we present up-to-date literature data, focusing on the role of OSA pathophysiology concepts concerning pharyngeal anatomical collapsibility and muscle responsiveness, underlying the response to OMT in OSA patients. Full article
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