Treatment for obstructive sleep apnea (OSA) continues to advance, from the increasingly sophisticated realm of wearables, to evolving approaches in OSA patients who also have insomnia and post-traumatic stress disorder (PTSD), to new techniques for implantable devices. Expert panelists discussed the advances in a session at the 2022 Triological Society Combined Sections Meeting.
Updated Wearables
Jolie Chang, MD, chief of sleep surgery and general otolaryngology at the University of California, San Francisco, said that the field is well positioned to use wearable sleep-tracking technology, as well as “nearables,” or items that measure sleep when placed near a patient, such as smart beds and certain smart phone apps.
“One-third of the U.S. population reports tracking their sleep,” she said. “We also know that insufficient sleep or poor sleep is common and related to health, so many people are motivated to understand their health and sleep better.”
Tracking sleep with wearables, which use sound and movement to estimate the quality of sleep, to help with sleep-disordered breathing makes sense because it’s a relatively common condition and patients are already armed with the tools needed to track it. “Providers and patients are set to benefit from sleep-tracking technology,” Dr. Chang said. “Patients are doing it anyway—they’re showing up at the clinic and saying, ‘Look at my sleep quality. It’s really been dipping since COVID-19,’ or, ‘My restfulness numbers are bad these days.’ A lot of patients are asking us about their metrics.”
One-third of the U.S. population reports tracking their sleep. We also know that insufficient sleep or poor sleep is common and related to health, so many people are motivated to understand their health and sleep better. —Jolie Chang, MD
When it comes to OSA, the use of sleep-tracking metrics seems to result in an increased use of continuous positive airway pressure (CPAP) (Sleep. 2015 Aug 1;38:1229-1236). These technologies can also help provide a sense of how well therapy has affected outcomes—for example, by measuring changes in snoring volume.
On the other hand, Dr. Chang said these consumer wearables and apps aren’t true medical devices and their data collection typically hasn’t been validated by polysomnography. In addition, they use proprietary algorithms that change routinely.
Most wearables are being studied in healthy populations rather than in those with sleep disorders, which could affect the reliability among those with sleep disorders. There has been some individual use of apps in sleep disordered patients. The SnoreLab app, which captures sound to quantify snoring levels during sleep, can be helpful in gauging progress after hypoglossal nerve stimulation surgery and during setting titration, Dr. Chang said. She reviewed an example case of one patient who had a very high snoring score of 93 on the app, which dropped to 25 after receiving his implant.
The most promising aspects of wearable and other app-related technology, at this point, might be the patient-directed motivation to improve sleeping habits and to boost treatment compliance, Dr. Chang said. “It’s limited currently by the lack of validation and accuracy, but may be helpful in longitudinal care,” she said.
OSA and Insomnia
Treating patients who have obstructive sleep apnea with comorbid insomnia involves a complex layering of considerations, since their sleep can be disrupted for a variety of reasons that can feed off one another, said Reena Dhanda Patil, MD, associate professor of otolaryngology and director of the Veterans Affairs Otolaryngology–Head and Neck Cancer Service at the University of Cincinnati in Ohio. These patients often have PTSD as well, she said. The sleep apnea can lead to frequent awakenings, causing insomnia, which can lead to anxiety about not being able to sleep, and on and on, she said.
“When you lump the two together you get everything,” she said. “It’s hard to figure out what’s being caused by what.” Insomnia is seen in about 50% of OSA patients, she said.
This means that when patients are considering hypoglossal nerve stimulation for their OSA, the implantation is only part of the challenge, she said. The underlying issues with sleep must be addressed for the implant to work, Dr. Dhanda said. “The device isn’t magic. It only works if you sleep,’” she said.
Dr. Dhanda believes that OSA patients would benefit if cognitive behavioral therapy were more readily available to them. “Our psychology colleagues are very important,” she said. “It [cognitive behavioral therapy] is the best therapy for insomnia that’s out there, but it unfortunately isn’t as easy to access as a sleeping pill. You can easily write someone a prescription for zolpidem, but you can’t easily find them a really competent CBT provider unless you search for one.”
Hypoglossal Nerve Stimulation
Maria Suurna, MD, an associate professor and the director of sleep surgery at Weill Cornell Medicine in New York City, said techniques for hypoglossal nerve stimulation are advancing. A two-incision approach, rather than using three incisions, has been shown to be noninferior and a safe and effective option for implantation of a device made by Inspire. Fewer complications and a shorter recovery time have been reported (Otolaryngol Head Neck Surg. Published online November 30, 2021. doi:10.1177/01945998211062150).
Although the United States differs from other countries by mostly limiting insurance coverage for the procedure to those with a body mass index (BMI) of 32 or below, Dr. Suurna noted that a registry study found that others might benefit as well. Results for those with a BMI of 32 to 35 were noninferior to those with a BMI of 32 or below when it came to change in apnea-hypopnea index, she said. Those with the higher BMI, however, were less likely to achieve mild or no sleep apnea (Laryngoscope. 2021;131:2616-2624).
A newer device with no implantable battery called the Genio is currently in clinical trials in the United States, Dr. Suurna said. Most trials exclude patients with complete concentric collapse (CCC) at the velopharynx, but the procedure using the Genio might be an option for these patients, she said. A study on patients with CCC and patients without CCC is also underway in Australia and New Zealand. No results have been released, but a case report shows good results for one patient with CCC who had severe sleep apnea (Clin Case Rep. 2021;9:2222-2224). “Hopefully we’ll be able to implant patients with complete concentric collapse in the future,” Dr. Suurna said.
In another encouraging sign for the field, combining ansa cervicalis stimulation, a neurostimulation mechanism for generating caudal pharyngeal traction, combined with hypoglossal nerve stimulation resulted in a greater cross-sectional measurement of the airway and in expiratory airflow (Chest. 2021;159:1212-1221).
It’s important to select patients carefully when deciding whether to move forward with hypoglossal nerve stimulation, said Dr. Dhanda. Their sleep habits, mental health history, pain issues, use of sleep aids, and nocturia all need to be considered. Physicians should try to answer the question of why CPAP didn’t work for these patients. “I’m almost always on the phone with, emailing, or messaging their referring physicians to figure out how we can help them with some of these issues,” she said.
Thomas R. Collins is a freelance medical writer based in Florida.