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Original Investigation
June 4, 2020

Evaluation of Therapeutic Positive Airway Pressure as a Hypoglossal Nerve Stimulation Predictor in Patients With Obstructive Sleep Apnea

Author Affiliations
  • 1Perelman School of Medicine, Department of Otorhinolaryngology–Head and Neck Surgery, University of Pennsylvania, Philadelphia
  • 2Division of Sleep Medicine, Department of Medicine, University of Pennsylvania, Philadelphia
  • 3Department of Medicine, Universidad Peruana Cayetano Heredia, Lima, Peru
JAMA Otolaryngol Head Neck Surg. Published online June 4, 2020. doi:10.1001/jamaoto.2020.1018
Key Points

Question  Is therapeutic nasal positive airway pressure at the soft palate during drug-induced sleep endoscopy associated with response to hypoglossal nerve stimulation in patients with obstructive sleep apnea?

Findings  In this cohort study of 27 consecutive patients with obstructive sleep apnea undergoing therapeutic nasal positive airway pressure during drug-induced sleep endoscopy, those who responded to hypoglossal nerve stimulation had significantly lower palatal opening pressures than nonresponders (5.0 vs 9.2 cm H2O, respectively). A palatal opening pressure cutoff level less than 8 cm H2O was associated with a positive predictive value.

Meaning  Airway distensibility, as measured by the palatal opening pressure in administration of therapeutic nasal positive airway pressure during drug-induced sleep endoscopy, may be a physiologic predictor of hypoglossal nerve stimulation success.


Importance  Recent retrospective hypoglossal nerve stimulation (HGNS) outcomes data suggest that patients with low therapeutic positive airway pressure (PAP) levels achieve greater success than patients with high therapeutic PAP levels.

Objective  To examine the use of therapeutic nasal PAP levels at the soft palate in predicting the outcomes of HGNS for patients with obstructive sleep apnea.

Design, Setting, and Participants  This prospective cohort study used drug-induced sleep endoscopy (DISE) to evaluate the predictive capacity of therapeutic PAP levels in HGNS outcomes. In an academic sleep surgery center, 27 consecutive patients with obstructive sleep apnea who underwent DISE before implantation of an HGNS device were evaluated. The study was conducted from May 1, 2018, to June 26, 2019.

Exposures  Positive airway pressure delivered through a nasal mask during DISE.

Main Outcomes and Measures  Improvement in apnea-hypopnea index as measured from full-night preoperative and postoperative efficacy studies.

Results  Twenty-seven patients met all inclusion criteria. The mean (SD) age was 62.0 (14.4) years, 14 participants were men (51.9%), and mean body mass index was 28.1 (4.0). Responders to HGNS therapy (n = 18) had significantly lower mean (SD) palatal opening pressure compared with nonresponders (n = 9) (5.0 [2.8] vs 9.2 [3.7] cm H2O, respectively; mean difference, −4.2; 95% CI, −6.8 to −1.6 cm H2O). After adjusting for age, sex, and body mass index, the mean palatal opening pressure value for the responders remained 3.5 cm H2O lower (95% CI, −6.7 to −0.4 cm H2O) than that of nonresponders. A palatal opening pressure cutoff level less than 8 cm H2O demonstrated a positive predictive value of 82.4%; sensitivity, 77.8%; and specificity, 66.7%.

Conclusions and Relevance  In this small prospective cohort study, therapeutic nasal PAP levels during DISE differed significantly between responder and nonresponders to HGNS. Because DISE represents a mandatory, relatively standardized diagnostic tool for HGNS candidacy, the use of therapeutic nasal PAP through DISE can be broadly implemented and studied across multiple centers to possibly improve patient selection for HGNS.

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