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Obstructive Sleep Apnea and Pharyngeal Size: Discussion (3)

Obstructive Sleep Apnea and Pharyngeal Size: Discussion (3)There was wide variability among patients. Separating patients into two groups according to their AHI, we were able to show that those patients with high apnea-hypopnea indices (group A) did improve significantly; however, they still had greater than 50 events per hour. In addition, the events that they had during the follow-up study were just as severe as the initial events as shown by the other respiratory parameters recorded. The less severe group (group B) did not demonstrate any significant improvement in any respiratory parameter and their AHI actually tended to be worse on the follow-up study.
We were also unable to show any statistically significant change in their sleep stages—some had more stage 3 and 4 and some had less, some had more REM and some had less.
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Obstructive Sleep Apnea and Pharyngeal Size: Discussion (2)

Decreased edema could lead to an increase in pharyngeal size making obstruction less likely. Another cause for this apparent improvement could be due to “better sleep.” Sleep deprivation has been shown to increase the severity of OSA possibly by inadequate activation of the genioglossus muscle. It has also been shown that nasal CPAP therapy decreases light stage sleep (stages I and 2) and increases slow wave and REM sleep. One could postulate that the improvement that occurs in OSA after nasal CPAP therapy is due to a superior sleep profile resulting from improved genioglossal muscle tone. One other possible reason for the improvement in underlying sleep apnea after nasal CPAP use could be from weight loss during the time of CPAP use. It has been conclusively shown that weight loss will improve OSA, and if patients did lose weight during the CPAP period, the improvement could be from the weight loss rather than the use of CPAP alone.
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Obstructive Sleep Apnea and Pharyngeal Size: Discussion (1)

Obstructive Sleep Apnea and Pharyngeal Size: Discussion (1)Over the past decade nasal CPAP has been shown to be an extremely effective form of therapy for OSA. It has obviated the need for tracheostomy in a large number of patients and has been shown to improve daytime arterial blood gas values as well as possibly improve mortality. Nasal CPAP, however, is not without problems. The majority of patients tolerate nasal CPAP well. Conversely, some patients are unable or unwilling to use the appliance for a variety of reasons: chest discomfort, feelings of suffocation, noise, fear of ridicule, etc. Even for those patients who do use nasal CPAP on a regular basis, many do not use it every night for the whole night.
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Obstructive Sleep Apnea and Pharyngeal Size (12)

However, analyzing the data by separating patients with an AHI greater than 50 (group A) vs patients with an AHI less than 50 (group B), we were able to show statistically significant differences. Group As AHI decreased from 87.3±19.1 events per hour on SS, to 61.0±32.5 events per hour on SS2 (p = 0.037). Group Bs AHI increased from SS, to SS2, 20.6 ± 13.1 events per hour to 32.7 ± 16.3 events per hour; however, this was not statistically significant. Group A patients were larger than group B patients, group As BMI = 39.5±4.6 kg/ sq m, and group Bs BMI = 29.6±3.7 kg/sq m (p = 0.002).
Examination of other parameters of disordered breathing during part 1 for the two groups or for the group overall did not reveal any significant changes from SSI to SS2 (Table 3).
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Obstructive Sleep Apnea and Pharyngeal Size (11)

Obstructive Sleep Apnea and Pharyngeal Size (11)Sleep Studies
We have chosen to divide the sleep studies into two parts: part 1 includes all the sleep and respiratory data for the time spent without nasal CPAP on; part 2 includes all the sleep and respiratory data for the time spent with nasal CPAP on. To reemphasize, patients spent the initial part of the night for both the initial (SSJ and follow-up (SS2) sleep studies without nasal CPAP on and the latter part of the night with nasal CPAP in place.
For part 1 (see Table 2), there were no significant differences between time in bed, SPT, or TST between SSi and SS2. Likewise, there were no significant differences between the sleep stages recorded as percentage of TST, including stages 1 + 2, stages 3-1-4, or REM.
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Obstructive Sleep Apnea and Pharyngeal Size (10)

Two patients experienced mild weight loss during the study, one went from 112.5 kg to 108.0 kg, and the other went from 128.8 kg to 124.2 kg. None of the other patients’ weights changed more than 2 kg during their study period.
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Obstructive Sleep Apnea and Pharyngeal Size (9)

Obstructive Sleep Apnea and Pharyngeal Size (9)We have validated this technique using control objects. Since a different scanner was used than in the previous article, we again scanned control objects with the same technique as the patients. Known volumes of mineral oil and cheese were scanned and digitized. The mineral oil was scanned while sitting in “boats” of clay molded in various shapes to emulate the contour of the upper airway. The cheese (mozzarella) was also cut into various shapes and water volume displacement was used to determine its actual volume. The digitized volume was compared with the actual volume. The coefficient of correlation was excellent overall with r = 0.9981, virtually identical to the previously published calibration.
Statistical analysis were done using a correlated t test for comparison of sleep study parameters and analysis of variance (ANOVA) for repeated measures for comparison of the pharyngeal volumes.
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Obstructive Sleep Apnea and Pharyngeal Size (8)

Computation of pharyngeal volumes was done as described previously. A computer program using a digitizing pad (Numonics 2210, Montgomeryville, PA) was used. In summary, the pharyngeal airspace was outlined with a computer mouse using the beginning of the soft palate as the superior landmark and the back of the epiglottis as the inferior landmark. An area (in square centimeters) is calculated for each slice and then multiplied by 0.4 cm (the thickness of each slice) to approximate a volume. The sequence is repeated on each slice that involves the airway (n = 7 to 10) and then added together to give a composite volume. In addition, we divided the airway into three separate sections and calculated volumes for each section.

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Obstructive Sleep Apnea and Pharyngeal Size (7)

Obstructive Sleep Apnea and Pharyngeal Size (7)Definitions
Standard procedures were used to quantitate sleep events. Desaturation was defined as a reduction in oxygen saturation by 4 percent or more. Apnea was a cessation of airflow at the nose and mouth for greater than 10 s. Hypopneas were scored as a decrease in inspiratory flow coupled with desaturation. Sleep period time (SPT) was defined as the time from the onset of sleep to the last awakening in the morning. Total sleep time (TST) was sleep period time less any time the subject was awake after falling asleep. An apnea-hypopnea index (AHI) was defined as all the apneas plus all the hypopneas divided by TST.
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Obstructive Sleep Apnea and Pharyngeal Size (6)

The patients did not know that the machine had an internal clock.
At the end of approximately six weeks, the patient returned with his nasal CPAP machine and his diary for the second sleep study. As stated previously, this sleep study was done in the same manner as the initial sleep study with the exception that in some patients the monitoring time prior to the placement of nasal CPAP was longer.
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