JAGDEEP BIJWADIA
A CASE FOR THE PATIENT TREATMENT PATHWAY FOR ORAL DEVICE THERAPY
ith CPAP being the gold standard for treatment of obstructive sleep apnea , there hasn ’ t been a strong focus in sleep medicine on the patient treatment pathway for oral device therapy . There didn ’ t have to be , because it was assumed that patients were using the optimal therapy for OSA treatment . However , not every patient experiences successful outcomes with CPAP , simply because they aren ’ t using it . To be specific , many patients give up on CPAP . The American Journal of Epidemiology published a study in 2013 that stated that about 4 out of every 10 of CPAP patients are non-compliant . Once a physician uncovers a CPAP intolerant patient , they can try an oral device as a treatment option , and guide their patients down a patient treatment pathway for oral device therapy .
Recent evidence increasingly supports health outcomes with oral devices being equivalent to CPAP in a wide range of conditions . In patients with mild to moderate OSA , improvements in sleepiness , quality of life and blood pressure are similar . Recent studies by Dr . Cistulli have confirmed equivalent outcomes in both groups in patients with moderate and severe OSA with cardiovascular outcomes like aortic augmentation index as well as driving simulation . A recent article by Charitte looked at cardiac autonomic function , and again outcomes with oral devices were comparable to CPAP .
The conclusion that oral devices and CPAP could have similar health outcomes has been difficult to explain given the many studies that show CPAP decreases AHI more effectively . A recent article published in the Journal of Dental Sleep Medicine helps put these findings into perspective . The article points out the difference between efficacy that is a measured outcome – in this case AHI in “ ideal ” circumstances ( the assumption being that the patients 100 % compliant ) – versus effectiveness which takes into account “ real life ” use .
4 out of every 10 of CPAP patients are non-compliant .
While CPAP is indeed more effective in reducing AHI , this is offset by the many studies confirming higher compliance rates with oral devices both when measured subjectively and objectively . The ideal metric for treatment should take into account both the AHI and the compliance . Drs . Cistulli and Sutherland introduced the idea of SARAHI sleep adjusted residual AHI , which is a metric that can be easily calculated and is reflective of the effectiveness of each therapy .
HOW TO CALULATE SLEEP ADJUSTED AHI :
SLEEP ADJUSTED AHI = ( AHI x NUMBER OF HRS ON TX ) + ( AHI x NUMBER OF HRS w / oTX ) / TOTAL HRS OF SLEEP
The sleep adjusted AHI is equal to the AHI multiplied by the number of hours on treatment which is then added to the AHI multiplied by the number of hours without treatment which is then divided by the total hours of sleep .