EFFECTS OF NASAL OBSTRUCTION AND CORRECTION IN SLEEP APNEA. Michael Friedman, MD

Transcription

1 EFFECTS OF NASAL OBSTRUCTION AND CORRECTION IN SLEEP APNEA Michael Friedman, MD

2 The Nasal Exam

3 Nasal Obstruction in OSA Nasal obstruction is often found in patients with OSA Nasal valve collapse, DNS, turbinate hypertrophy, sinus disease, polyps Identified as an independent risk factor in the pathogenesis of OSA 1,2 1. Lofaso F, et al. Eur Respir J. 2003;22: Virkkula P, et al. Laryngoscope 2003;113:

4 Nasal Obstruction in OSA No definitive evidence of a causal relationship 1,2 No correlation between nasal patency and severity of OSA 3 1. Ohki M, et al. Acta Otolaryngol Suppl 1996; 523: Miljeteig H, et al. Laryngoscope 1992; 102: Schechter GL, et al. Otol Head Neck Surg. 1998;118:643-7.

5 Nasal Obstruction in OSA Complete nasal obstruction can be simulated with postoperative nasal packing (PNP) Previous studies have revealed conflicting results Nasal packing in healthy patients 1-3 Surgical correction of nasal obstruction for treatment of OSA 4,5 1. Suratt P, et al. Chest. 1986;90: Zwillich C, et al. Am Rev Respir Dis. 1981; 124: Taasan V, et al. Laryngoscope. 1981;9: Regli A, et al. Anesth Analg. 2006;102: Verse T, et al. Laryngoscope 2002; 112:64-68.

6 Rotenberg and Tam 2010 Systematic review of posterior nasal packing (PNP) causing respiratory complications Results: 14 included studies 7 case series, 3 cohort, 4 reviews 6 studies discussed pulmonary mechanics 3 studies discussed sleep apnea Complications discussed in 2 reviews and 3 articles focusing on posterior epistaxis treatment Rotenberg B and Tam S. Respiratory complications from nasal packing: systematic review. J Otolaryngol Head Neck Surg. 2010;39(5):

7 Rotenberg and Tam 2010 Results: 3 studies found on PNP & Sleep Apnea: all observational and based on case series Wetmore et al 1998 Vaartjes et al 1992 Armengot et al 2008 All 3 studies noted some nocturnal oxygen desaturation and/or apnea with PNP No study had data on pre-packing sleep measurements Conflicting data on improvement after PNP removal, with minimal data on AI and AHI Conclusion: Mild sleep apnea may develop with nasal packing Rotenberg B and Tam S. Respiratory complications from nasal packing: systematic review. J Otolaryngol Head Neck Surg. 2010;39(5):

8 Rotenberg and Tam 2010 Results: PNP & Pulmonary Function: 3 of 6 studies found some change in blood gases with PNP Complications of PNP: 2 reviews and 3 articles showing possible hypoxemia with PNP Conclusion: Lack of evidence showing that posterior packing puts all patients at risk for respiratory events Rotenberg B and Tam S. Respiratory complications from nasal packing: systematic review. J Otolaryngol Head Neck Surg. 2010;39(5):

9 Nasal Obstruction in OSA Nasal Packing Worsens Respiratory Parameters Turhan et al 2013 Nasal packing after septoplasty significantly worsens AHI and ODI compared to transseptal suture Friedman et al 2011 Nasal packing significantly worsens RDI and ODI in patients with mild OSA Armengot et al % of patients (37 of 40) had worsened ODI with nasal packing, with 47.5% (19 of 40) had ODI 12 Regli et al 2006 AHI and ODI worsened with packing in healthy patient group, only AHI worsened with packing in OSA patients Morita et al 2004 Nasal packing pre-operatively worsened AHI in 31% (5 of 16) of pediatric patients, and correlated with post-operative AHI 2 weeks after pharyngeal flap surgery Vaartjes et al 1992 Central, obstructive, or mixed apneas may result from nasal packing Jensen et al 1991 Significant increase in number of hypoxic episodes with nasal packing Wetmore et al 1988 OSA is present in patients with nasal packs for treatment of posterior epistaxis Suratt et al 1986 Intranasal obstruction produces apneas and hypopneas

10 Nasal Obstruction Study: Objective and Study Design To compare the effect of postoperative nasal packing on sleep parameters between patients with mild OSA and patients with moderate/severe OSA Prospective, non-randomized controlled study in a tertiary care institution Friedman M, Maley A, Kelley K, Leesman C, Patel A, Pulver T, Joseph N, Catli T. Impact of nasal obstruction on obstructive sleep apnea. Otolaryngol Head Neck surg. 2011;144(6):

11 Nasal Obstruction Study: Methods: Patient Selection 49 consecutive patients with history of significant snoring scheduled to undergo nasal surgery requiring post-operative nasal packing Inclusion criteria Age 18 BMI 40 Willingness to undergo preoperative and postoperative polysomnogram Exclusion criteria Concomitant upper airway surgery Sleep time < 4 hours in either study Postoperative complications

12 Nasal Obstruction Study: Methods Preoperative overnight sleep study completed within 30 days prior to surgery At home and without nasal packing Postoperative sleep study completed with nasal packing in place

13 Nasal Obstruction Study: Results 49 Patients met inclusion criteria n=26 n=23 Group 1 Mild OSA RDI < 15 Group 2 Moderate/Severe RDI 15

14 Group 1 (Mild OSA)

15 Group 2 (Moderate/Severe OSA)

16 Nasal Obstruction Study: Conclusion Nasal packing significantly worsens RDI and ODI in patients with mild OSA Nasal packing does not significantly impact RDI and ODI in patients with moderate/severe OSA

17 Turhan et al 2013 Prospective randomized study in patients without OSA, testing changes in respiratory parameters with nasal packing Methods: 43 septoplasty patients received pre and post-surgery PSG: 23 patients had nasal packing inserted post-surgery, 20 had transseptal suture Results: Nasal Packing Group: AHI in significantly increased from 1.65 ±0.27 to 3.83±0.53 Lowest O2 saturation significantly decreased from 92.43% to 90.30% Transseptal Suture Group: AHI increased significantly from 1.5±0.24 to 2.08±0.29 No significant change in lowest O2 saturation Turhan M, Bostanci A, Mehmet A. A comparison of the effects of packing or transseptal suture on polysomnographic parameters in septoplasty. Eur Arch Otorhinolaryngol. 2013;270:

18 Does it help? Nasal surgery can cure OSA by objective parameters Wang et al 2014 Success rate: 75.3% Park et al 2014: Success Rate: 56% Hu et al 2013 Success Rate: 22.7% Morinaga et al 2009 Success Rate: 22.9% Kim et al 2004 Success Rate: 19% Verse et al 2002 Success Rate: 15.8% Koutsourelakis et al 2008 Success Rate: 14.8% Yalamanchali et al 2014 Success Rate: 3.6% Virkkula et al 2006

19 Does it help? Only helps with subjective symptoms Yang et al 2013 Choi et al 2011 Li et al 2009 Tosun et al 2009 Li et al 2009 Nakata et al 2008

20 Li et al 2011 Li et al conducted a meta-analysis of nasal surgery as treatment for OSA Nasal surgery involved combinations of septoplasty, submucous resection of septum, inferior turbinate resection, and/or endoscopic sinus surgery Outcomes measured included AHI, O2 saturation, subjective symptoms Li HY, Wang PC, Chen YP, Lee LA, Fang TJ, Lin HC. Critical appraisal and metaanalysis of nasal surgery for obstructive sleep apnea. Am J Rhinol Allergy. 2011;25(1):45-9.

21 Li et al original articles Pooled n = 474 patients Surgery Performed: Septoplasty Only (2 studies) Septoplasty & Turbinate Resection (7 studies) Septoplasty, Turbinate Resection, & Endoscopic Sinus Surgery (4 Studies) Li HY, Wang PC, Chen YP, Lee LA, Fang TJ, Lin HC. Critical appraisal and metaanalysis of nasal surgery for obstructive sleep apnea. Am J Rhinol Allergy. 2011;25(1):45-9.

22 Li et al 2011 Results: Weighted mean AHI +/- SD decreased from / to / (p=0.69) Pooled success rate of nasal surgery in treating OSA was 16.7% (95% CI = , p <0.0001) Significant symptomatic improvement by ESS, VAS, SOS, SBPS scales Conclusion: nasal surgery in OSA patients improves clinical symptoms but is not efficacious in treating OSA Li HY, Wang PC, Chen YP, Lee LA, Fang TJ, Lin HC. Critical appraisal and metaanalysis of nasal surgery for obstructive sleep apnea. Am J Rhinol Allergy. 2011;25(1):45-9.

23 Studies included septoplasty, turbinate surgery with or without endoscopic sinus surgery Would the addition of valve repair change results?

24 Nasal Dilators for OSA treatment Nasal Dilator Studies Krakow et al 2006 Significant symptomatic improvement Schonhofer et al 2000: 19% response rate in RDI Hoijer et al 1992: Increase in nasal airflow, mean decrease in AI by 47% Studied in 10 patients with no data on AHI Breathe Right Strips Gosepath % showed some reduction in RDI Wenzel et al 1997 No change in objective measurements, some symptomatic improvement Ulfberg et al 1997 Significant symptomatic improvement Nozovent Nasal Dilator

25 A simplified technique for airway correction at the nasal valve area

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29 Nasal Valve Repair

30 Endoscopic Sinus and Nasal Surgery: Objective and Study Design To evaluate the impact of combined nasal surgery and endoscopic sinus surgery on objective measurements of OSA Case series with chart review in a tertiary care institution Yalamanchali S, Cipta S, Waxman J, Pott T, Joseph N, Friedman M. Effects of endoscopic sinus surgery and nasal surgery in patients with obstructive sleep apnea. 2014;151(1):

31 Endoscopic Sinus and Nasal Surgery: Methods 56 Patients with OSA and chronic rhinosinusitis who underwent combined nasal surgery and endoscopic sinus surgery and had data available on pre and postoperative PSG Surgery All had septoplasty with bilateral submucosal inferior tubinate reduction and concurrent ESS Some had additional nasal valve repair and nasal polypectomy depending on pathology

32 Figure 1. Graphic representation of change in mean AHI after combined nasal and sinus surgery. Yalamanchali S et al. Otolaryngology -- Head and Neck Surgery 2014;151: Copyright by American Academy of Otolaryngology- Head and Neck Surgery

33 Endoscopic Sinus and Nasal Surgery: Results AHI: Mean pre-operative AHI 33.5+/- 22.0, post-operative AHI / Statistical reduction in AHI was achieved in moderate and severe sleep apnea groups, and in patients without nasal polyps No significant change in oxygen saturation Successful treatment of OSA was achieved in only 2 of 56 patients (3.6%) Significant increase in stage N1 sleep, but no significant change in sleep efficiency, or stages N2, N3, and REM

34 Endoscopic Sinus and Nasal Surgery: Conclusion Small but statistically significant reduction in AHI after combined nasal and sinus surgery in patients with moderate to severe sleep apnea and patients without nasal polyps No improved quality of sleep Overall limited efficacy of combined surgery in treating OSA

35 Nasal Correction Study: Objective and Study Design To compare the effect of an improved nasal airway on OSA Prospective, non-randomized controlled study in a tertiary care institution Friedman M, Tanyeri H, Lim JW, Landsberg R, Vaidyanathan K, Caldarelli D. Effect of improved nasal breathing on obstructive sleep apnea. Otolaryngol Head Neck surg. 2000;122(1):71-4.

36 Nasal Correction Study: Methods 50 patients with OSA who required surgical treatment for nasal airway obstruction Included patients were symptomatic and had documented anatomic cause of nasal airway obstruction, as well as documented OSA

37 Nasal Correction Study: Methods Surgery: All patients had submucous resection of septum +/- bilateral inferior turbinate resection Some also underwent endoscopic sinus surgery for history of recurrent sinusitis. Patients with chronic sinusitis were excluded

38 Nasal Correction Study: Results Subjective Measures: 49 of 50 (98%) of patients reported improved nasal breathing 17 of 50 (34%) reported decreased or resolved snoring symptoms 39 of 50 (78%) reported increased daytime energy Objective Measures: No significant change in overall mean RDI Mild OSA had significantly increased overall RDI No significant decrease in O2 saturation CPAP pressures needed for OSA treatment significantly decreased

39 Nasal Correction Study: Conclusion RDI level is not likely to be corrected or improved with nasal surgery Nasal surgery can provide subjective symptom improvement Nasal airway reconstruction may decrease CPAP levels needed to treat OSA

40 Nasal Correction & CPAP Poirier et al 2014: Significant increase in CPAP compliance after septoplasty (0.5 hrs/night to 5 hrs/night) in CPAP-intolerant OSA patients with documented nasal obstruction Nakata et al 2005 Nasal surgery in 12 CPAP-intolerant patients made all patients tolerant to CPAP and significantly decreased nasal resistance Friedman et al 2000 Results as above Series et al 1992 Significant decrease in nasal resistance and decreased CPAP pressures after nasal surgery, but no difference in respiratory disturbances or total apnea time

41 In Conclusion Nasal obstruction can worsen respiratory parameters Nasal septal, turbinate, valve, sinus surgery (when indicated) has significant success in improving sleep symptoms and quality of life Nasal Surgery is often an important first step in multi-level surgery for OSA has an impact on CPAP optimal pressures and compliance Objective correction of OSA occurs in less than 20% of patients

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