Louisville Medicine Volume 69, Issue 2 - Page 31

have , in my opinion , completely re-energized the field .
Because of our clinical research program which we began in 2001 , I was approached in 2011 to participate in a clinical trial which looked at the safety and efficacy of hypoglossal nerve stimulation ( HGNS ) for the treatment of OSA . This clinical trial allowed a deep dive into the pathophysiology of OSA in conjunction with extensive cadaver lab training , as well as the opportunity for close collaboration with a local sleep expert Dr . David Winslow . Ultimately , we implanted 14 patients with an experimental device .
In 2014 , I was an investigator in a secondary HGNS trial . In 2015 , a third device gained FDA approval and became available to treat OSA patients . We became one of the first sites in the country to treat patients with HGNS . Although the launch was extraordinarily difficult because of hospital and insurance acceptance , to date we have implanted over 100 patients , locally . I am extraordinarily proud of my team ’ s results . Although we continue to carefully collect data through the National Adhere Registry , we currently have the results of 44 consecutive patients who show an average decline of apnea hypopnea index ( AHI ) by 78 %. This is in line with or exceeds published data .
One of the unexpected results of performing the implant procedures was how much I learned from the FDA-required pre-operative drug-induced sleep endoscopy ( DISE ) screening . We gradually sedate patients with propofol in our outpatient surgery center and attempt to mimic normal sleep the patient would have at home . During this procedure , we perform airway endoscopy while monitoring several physiologic parameters . This procedure offers a uniquely dynamic evaluation of the airway . By doing this , we were able to characterize the type and level of obstruction .
After performing a few hundred of these procedures , using the same anesthesiologist , we have been able to refine this technique so that , in my opinion , we are able to make better recommendations for all treatments of OSA , not just surgery . For example , in about 10 % of cases , the patient has primarily hypopharyngeal obstruction due to a prolapsing epiglottis . These patients respond poorly to PAP , but may improve with positional therapy or be cured by epiglottic surgery . Patients frequently feel vindicated when I tell them that their PAP was in fact smothering them . of a traditional excisional UPPP , sleep disordered breathing surgery encompasses a wide variety of procedures and approaches , many of which are much less invasive ( and much more successful in outcome ). From an ENT perspective , a whole new treatment window has opened for helping achieve the practical , objective , long-term success goals we want for our patients . Also we need to acknowledge that suboptimal use of optimal therapy such as PAP may actually be inferior to suboptimal surgery when it has a continuous effect . Fortunately , I believe we have moved beyond pitting various therapies against each other and we are more focused on helping people .
If health care trends continue , the field of sleep-disordered breathing will need to adapt to a patient-centered individualistic approach . We will need to harness smartphone and Bluetooth technology , and very soon , artificial intelligence may also be used in reporting and analyzing data for both diagnostic and treatment plans . Ultimately , our job is to optimize our patients ’ health and quality of life with all the tools available to us .
This an exciting time in sleep medicine . Siloing patient care according to specialty no longer makes sense . All physicians need to , and should work towards , the common goal of contributing to the best practice for each patient .
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Senior BA , Rosenthal L , Lumley A , et al . Efficacy of uvulopalatopharyngoplasty in unselected patients with mild obstructive sleep apnea . Otolaryngol Head Neck Surg 2000 ; 123:179-82 .
Gay P , Weaver T , Loube D , et al . Evaluation of positive airway pressure treatment for sleep related breathing disorders in adults . Sleep 2006 ; 29:381-401 .
Kalan A , Kenyon GS , Seemungal TA , et al . Adverse effects of nasal continuous positive airway pressure therapy in sleep apnea syndrome . J Laryngol Otol 1999 ; 113:888-92 .
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Dr . Gould , FAAOA practices at Advanced ENT and Allergy .
In my experience , if we utilize multiple variables such as standardized oropharyngeal classifications , BMI , sleep studies , validated quality-of-life measures and DISE , then all of our treatment options , whether surgical or non-surgical , can be more effective . In addition , our surgical results can be predictable and reliable . By studying the dynamic airway , we can functionally rearrange tissue rather than just resecting it .
I believe it is time for a paradigm shift in OSA surgery . Instead
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