The Upper Airway Resistance Syndrome: Oral Appliances

The Upper Airway Resistance Syndrome: Oral AppliancesOral Appliances
Oral appliances that advance the mandible and tongue are already used to treat OSAS. These devices hold promise for treating UARS because of good patient acceptance and low morbidity, but, unfortunately, there are almost no data available to support their use. Loube et al reported a well-documented case of a 40-year-old man with UARS who was successfully treated using an oral appliance. The patient had declined CPAP at 9 cm H2O after a 2-month trial because of subjective increased sleep fragmentation. A repeat PSG following 2 weeks of therapy with a mandibular advancement device showed a decreased arousal index from 53 to 10/h, a decreased IUAR index from 44 to 2 events/h, an improved mean (± SD) Pes nadir from —5 ± 2 to —5 ± 3 cm H2O, and improved sleep efficiency. The patient’s ESS score decreased from 17 to 6, and he denied any side effects or complications. If an extensive series or a similarly well-documented prospective trial can show a reasonable percentage of patients with this type of result, this may become a very important treatment modality for UARS. Read the rest of this entry »

The Upper Airway Resistance Syndrome: Surgical interventions

Newman and colleagues published a prospective evaluation of surgical intervention in patients presenting over a 1-year period with snoring and EDS; only patients with Pes nadirs < —10 cm H2O and RDIs of < 5 were included. All nine patients reportedly opted for surgical interventions, including septoplasty with turbinate reduction, LAUP, UPPP, mandibular osteotomy with tongue advancement, and hyoid myotomy with suspension. The mean (± SD) pretreatment Pes nadir was —36.7 ± 16.2 cm H2O, but only two patients underwent postoperative PSG with Pes measurements. After treatment, their respective Pes nadirs had changed from — 52 to —40 cm H2O and from —30 to —17 cm H2O, which are still in ranges that are lower than the generally accepted normal range of —10 cm H2O. The authors also reported an impressive change in the mean (± SD) ESS score from 12 ± 6.6 to 3.4 ± 1.9, although three of the nine patients had initial scores within the normal range of < 7. Read the rest of this entry »

The Upper Airway Resistance Syndrome: Surgery

The Upper Airway Resistance Syndrome: SurgeryRauscher and colleagues also studied nCPAP in nonapneic snorers, defined as patients with EDS and an AHI of < 5. These patients had a mean (± SD) 3- to 15-s EEG arousal index of 20 ± 10/h. Therefore, this was a more homogeneous population, and many of them likely had UARS, although, again, no invasive monitoring was used. Only 19% of the patients (n = 11) accepted nCPAP therapy, with a mean (± SD) daily use time at 6 months of 2.8 ± 1.5 h. Surprisingly, 73% of the acceptors reported decreased sleepiness with therapy. Again, the patients were offered the option of surgical therapy, and 11 chose UPPP. Although the acceptors had slightly more apneas and hypopneas than the refusers, they did not differ in arousal index, initial EDS, BMI, age, or percent of SWS. Thus, the authors were unable to determine any reliable criteria that could predict CPAP acceptance or compliance. Read the rest of this entry »

The Upper Airway Resistance Syndrome: Treatment

CPAP, surgery, oral appliances, and weight loss are all viable treatment modalities for UARS, and they have received more recent attention in the literature. Unfortunately, the data regarding compliance, efficacy, safety, or a combination of these factors are lacking in many cases. natural asthma treatment

In 1991, Guilleminault et al showed that in a group of 15 regular heavy snorers with UARS the institution of nCPAP resulted in significantly fewer arousals and improved MSLT scores. The CPAP values ranged from 3 to 8 cm H2O with a mean of5.8 cm H2O. Interestingly, none of these patients wanted to continue nCPAP beyond the study protocol, although daytime somnolence was not their primary complaint (the mean initial MSLT score was 11.29 min); therefore, these patients likely represented the mild end of the UARS clinical spectrum. Read the rest of this entry »

The Upper Airway Resistance Syndrome: Hypertension

The Upper Airway Resistance Syndrome: HypertensionGuilleminault et al reported similar results in 110 patients known to have UARS. In these patients, systolic and diastolic BP increased during the breaths associated with the arousal when compared to the BP measures that directly preceded the arousal. The systolic and diastolic BP also increased significantly during segments of labored breathing without the arousal Pes nadir (more negative than —30 cm H2O) in a subset of seven patients. Echocardiography demonstrated a leftward shift of the interventricular septum during segments with the most negative Pes nadirs (more negative than —35 cm H2O). Pulsus paradoxus was also demonstrated during these segments. Also shown were significant decreases in the average systolic and diastolic daytime BP as well as the average nocturnal diastolic BP in six patients with borderline hypertension who were treated with nCPAP for 1 month. Of note, one patient who was not compliant with nCPAP did not show these changes. Read the rest of this entry »

The Upper Airway Resistance Syndrome: Sequelae and Associated Disorders

Daytime Somnolence
By definition, daytime somnolence is a component of UARS and may be as severe as that found in OSAS. Guilleminault et al first demonstrated significant daytime somnolence by the MSLT and Wilkinson addition test scores, as well as behavioral abnormalities from UARS in a population of nonap-neic/nonhypopneic snoring children. These daytime sequelae were ameliorated after a tonsillectomy and/or an adenoidectomy. Nearly a decade later, these investigators presented results showing an improvement in MSLT scores in a large proportion of regular heavy adult snorers after the institution of nCPAP. Interestingly, snoring was the primary complaint of the 15 patients in that study. None of the patients spontaneously volunteered a history of daytime somnolence; this information was revealed only after direct questioning. Similarly, in these patients the mean pretreatment MSLT score of 11.29 min was within the normal range; however, after treatment the mean score was 14.59 min (p < 0.0001). Therefore, a wide range of daytime symptoms can be seen in this disorder. Read the rest of this entry »

The Upper Airway Resistance Syndrome: Upper airway impedance

The Upper Airway Resistance Syndrome: Upper airway impedanceRuhle and colleagues suggested in a recent review that upper airway impedance measurements using the forced oscillation technique may be useful as a surrogate of Pes in the diagnosis of UARS. With this technique, an airflow of 2 L/min is applied to a conventional nCPAP mask at an oscillatory frequency of 20 Hz. The researchers studied 25 nono-bese patients with EDS and a mean RDI of 3.4, Although the majority of arousals could not be explained on the basis of standard polysomnographic measurements, this technique showed IUAR in over half of these unexplained events. These authors also suggested that the pulse transit time (the time between the ECG R wave and the fingertip pulse shock wave) correlated with subtle changes in both the Pes and the arousals Reading here asthma medications inhalers. They also discussed changes in BP as a marker of IUAR because more negative intrathoracic pressure would decrease BP and arousal would increase BP. Read the rest of this entry »


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