"Given OSA is a highly prevalent disorder and is associated with impairment of quality of life, clinicians should strive towards treatment," Dr. Harneet Walia of Miami Cardiac and Vascular Institute, Baptist Health South Florida told Reuters Health by email. "PAP is the treatment of choice; however, if PAP does not work, alternative therapies such as HNS should be considered, given that treatment improves quality of life parameters."
"HNS is designed for patients with moderate to severe obstructive sleep apnea, who are unable to tolerate CPAP," she said. "HNS is not suitable for obese patients (BMI >35 Kg/m2), those with primarily central sleep apnea, those with concentric collapse of the soft palate and pregnant patient."
As reported in JAMA Otolaryngology-Head and Neck Surgery, Dr. Walia and colleagues analyzed data from OSA patients treated at Cleveland Clinic. Eighty-five patients received HNS; the mean age was 63; 69% were men; 91% were white and the mean BMI was 28.8. Two hundred and seventeen patients received PAP; the mean age was 62; 72% were men; 81% were men; and the mean BMI was 29.5.
Significant improvements were seen in Patient Health Questionnaire-9 (PHQ-9) scores for HNS versus PAP (mean difference, −1.48), with comparable improvements in Epworth Sleepiness Scale (ESS), Functional Outcomes of Sleep Questionnaire (FOSQ), and Insomnia Severity Index (ISI) scores.
Similarly, rates of clinically meaningful differences with HNS versus PAP were 65% versus 55% for ESS scores; 59% versus 31% for FOSQ scores; 29% versus 24.4% for PHQ-9 scores; and 47% versus 36.4% for ISI scores.
At the one-year post-HNS assessment, meaningful improvements were seen in 61% for ESS scores, 55% for FOSQ scores, 30% for PHQ-9 scores, and 44% for ISI scores.
The authors state, "In this cohort study of patients with OSA, sustained improvements in PROs were observed 1 year after HNS and were comparable to those for PAP at 3 months."
Dr. Alex Dimitriu, founder of Menlo Park Psychiatry and Sleep Medicine in California, commented in an email to Reuters Health, "I have seen a number of patients who have done well with HNS. However, in my patient population, these are patients who had significant and ongoing trouble tolerating PAP therapy."
"I am always reluctant to tell patients to have surgery, and thus will always lean towards a 'removable' treatment like CPAP over a more invasive procedure, such as an HNS device," he said. "For people with milder sleep apnea, the importance of weight loss and exercise cannot be underscored enough, and is a starting point even prior to CPAP."
"I believe clinicians should follow a step-wise progression from lifestyle modifications, to allergy and congestion optimization, to PAP, and lastly to anything surgical," he concluded.
Dr. Steven Thau, Division Chief of the Pulmonary and Sleep Medicine Department and Medical Director of the Sleep Center, Respiratory Therapy and the PFT Lab at Phelps Hospital/Northwell Health in Sleepy Hollow, New York, also commented by email. "The HNS patients in the study seemed to be slightly worse on the various scales compared to the PAP group, so there was a greater chance to show an improvement with HNS," he said.
Still, he noted, "there were improvements seen and these improvements lasted for a year, which is important for patients and clinicians who have a longer perspective."
"CPAP therapy is still the first-line therapy and is the only modality that shows cardiovascular benefits," he added. "It can improve sleepiness in mild, moderate and severe disease, and can be used at any age, even the medically frail, and can provide dramatic improvements in the most vulnerable."
The study was supported by Inspire, Inc for the conduct of research by Dr. Walia and one coauthor.
SOURCE: https://bit.ly/3wV57GX JAMA Otolaryngology-Head and Neck Surgery, online November 11, 2021.
By Marilynn Larkin
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