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Journal of Oral and Maxillofacial... Jul 2018The effects of noncontinuous positive airway pressure (non-CPAP) therapies on the airflow in the upper airway in obstructive sleep apnea (OSA) patients are not...
The Effects of Noncontinuous Positive Airway Pressure Therapies on the Aerodynamic Characteristics of the Upper Airway of Obstructive Sleep Apnea Patients: A Systematic Review.
PURPOSE
The effects of noncontinuous positive airway pressure (non-CPAP) therapies on the airflow in the upper airway in obstructive sleep apnea (OSA) patients are not completely clear yet. Therefore, the primary aim of this systematic review was to determine the effects of various non-CPAP therapies on the aerodynamic characteristics of the upper airway in OSA patients.
MATERIALS AND METHODS
A PICO (population or patient, intervention, comparison, outcome) search strategy, focusing on the effects of various non-CPAP therapies on the aerodynamic characteristics of the upper airway (ie, velocity, wall shear stress, wall static pressure, airway resistance, pressure drop, and pressure effort) of OSA patients, was conducted in the following databases: MEDLINE (PubMed), Embase (Excerpta Medica), and Web of Science. In this systematic review, the inclusion criteria were 1) adults diagnosed with OSA by polysomnography, 2) treatment outcome assessed by a second polysomnography, and 3) computational fluid dynamics (CFD) applied.
RESULTS
Of 51 unique studies retrieved, 9 fulfilled the criteria for this systematic review. Seven studies were on maxillomandibular advancement (MMA) surgery, and 2 were on mandibular advancement device (MAD) therapy. The aerodynamic characteristics of the upper airway improved in OSA patients who underwent MMA surgery. However, the studies on MMA surgery included only responders to MMA surgery. In the responders to MAD therapy, the velocity, wall static pressure, and airway resistance of the upper airway decreased. In nonresponders to MAD therapy, the wall static pressure and airway resistance of the upper airway increased.
CONCLUSIONS
This systematic review suggests that MMA surgery and MAD therapy may improve several aerodynamic characteristics of the upper airway in OSA patients by CFD analysis. However, because of limitations of the selected studies, there is not enough evidence yet to support CFD analysis as a routine tool to predict the treatment outcome in OSA patients.
Topics: Humans; Pharynx; Positive-Pressure Respiration; Sleep Apnea, Obstructive
PubMed: 29567436
DOI: 10.1016/j.joms.2018.02.017 -
Journal of Clinical Sleep Medicine :... Jan 2018Several studies have reported an association between obstructive sleep apnea (OSA) and several extra-pulmonary issues, such as arterial hypertension and insulin... (Meta-Analysis)
Meta-Analysis
STUDY OBJECTIVES
Several studies have reported an association between obstructive sleep apnea (OSA) and several extra-pulmonary issues, such as arterial hypertension and insulin resistance. In recent years, the associations between OSA, non-alcoholic fatty liver disease, and non-alcoholic steatohepatitis (NASH) have been published; however, there is a gap between experimental and clinical studies regarding the efficacy of continuous positive airway pressure (CPAP) treatment in patient populations with these conditions. This issue should be considered when deciding on CPAP treatment in patients with OSA, especially in patients with moderate OSA.
METHODS
We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) using the following databases: MEDLINE, Lilacs, and CENTRAL. Two independent reviewers performed the search, analysis, data extraction, and critical analysis.
RESULTS
From 622 identified studies, we included 5 RCTs that involved patients with OSA and NASH and who were treated with a CPAP device. After CPAP treatment, no changes in liver steatosis, liver fibrosis, and aminotransferase levels (alanine aminotransferase and aspartate aminotransferase) were found. Finally, the quality of evidence using the GRADE approach was low and very low for several outcomes.
CONCLUSIONS
According to the current analysis, no data regarding the efficacy of CPAP in patients with NASH are available to make recommendations.
SYSTEMATIC REVIEW REGISTRATION
PROSPERO; ID: CRD42015027981; URL: https://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42015027981.
Topics: Continuous Positive Airway Pressure; Humans; Non-alcoholic Fatty Liver Disease; Sleep Apnea, Obstructive
PubMed: 29151428
DOI: 10.5664/jcsm.6900 -
International Journal of... Feb 2019To investigate the effects of expiratory muscle strength training on communication and swallowing outcomes in adults with acquired motor based communication and/or...
PURPOSE
To investigate the effects of expiratory muscle strength training on communication and swallowing outcomes in adults with acquired motor based communication and/or swallowing difficulties of any aetiology.
METHOD
A systematic review was conducted. Six databases (CINAHL, MEDLINE, EMBASE, SPEECHBYTE, AMED and PUBMED) were searched from inception until end of May 2016. Randomised and non-randomised controlled studies and pre-test/post-test studies published in English that investigated the effects of expiratory muscle strength training were included. Study quality was assessed using the PEDro scale. Data were analysed descriptively and effect sizes and associated 95% confidence intervals were calculated.
RESULT
Seven articles reporting data from five studies were included. Preliminary data suggests expiratory muscle strength training improved airway safety during swallowing in people with dysphagia and increased the strength of the expiratory muscles in all patient groups. There was little evidence to suggest changes in communication outcomes after expiratory muscle strength training.
CONCLUSION
Speech-language pathologists might consider using expiratory muscle strength training to improve airway safety in adults with swallowing disorders.
Topics: Abdominal Muscles; Adult; Deglutition Disorders; Exhalation; Female; Humans; Intercostal Muscles; Male; Muscle Strength; Resistance Training
PubMed: 29090601
DOI: 10.1080/17549507.2017.1387285 -
The Clinical Respiratory Journal Mar 2018Chronic obstructive pulmonary disease (COPD) is often accompanied by acute exacerbations. Patients of COPD exacerbation suffering from respiratory failure often need the... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Chronic obstructive pulmonary disease (COPD) is often accompanied by acute exacerbations. Patients of COPD exacerbation suffering from respiratory failure often need the support of mechanical ventilation. Helium-oxygen can be used to reduce airway resistance during mechanical ventilation. The aim of this study is to evaluate the effect of helium-oxygen-assisted mechanical ventilation on COPD exacerbation through a meta-analysis.
METHODS
A comprehensive literature search through databases of Pub Med (1966∼2016), Ovid MEDLINE (1965∼2016), Cochrane EBM (1991∼2016), EMBASE (1974∼2016) and Ovid MEDLINE was performed to identify associated studies. Randomized clinical trials met our inclusion criteria that focus on helium-oxygen-assisted mechanical ventilation on COPD exacerbation were included. The quality of the papers was evaluated after inclusion and information was extracted for meta-analysis.
RESULTS
Six articles and 392 patients were included in total. Meta-analysis revealed that helium-oxygen-assisted mechanical ventilation reduced Borg dyspnea scale and increased arterial PH compared with air-oxygen. No statistically significant difference was observed between helium-oxygen and air-oxygen as regards to WOB, PaCO , OI, tracheal intubation rates and mortality within hospital.
CONCLUSIONS
Our study suggests helium-oxygen-assisted mechanical ventilation can help to reduce Borg dyspnea scale. In terms of the tiny change of PH, its clinical benefit is negligible. There is no conclusive evidence indicating the beneficial effect of helium-oxygen-assisted mechanical ventilation on clinical outcomes or prognosis of COPD exacerbation.
Topics: Helium; Humans; Oxygen; Positive-Pressure Respiration; Pulmonary Disease, Chronic Obstructive; Recurrence; Respiratory Insufficiency
PubMed: 28544519
DOI: 10.1111/crj.12654 -
Chest Sep 2017The mechanism by which various classes of medication reduce COPD exacerbation risk remains unknown. We hypothesized a correlation between reduced exacerbation risk and... (Meta-Analysis)
Meta-Analysis
BACKGROUND
The mechanism by which various classes of medication reduce COPD exacerbation risk remains unknown. We hypothesized a correlation between reduced exacerbation risk and improvement in airway patency as measured according to FEV.
METHODS
By systematic review, COPD trials were identified that reported therapeutic changes in predose FEV (dFEV) and occurrence of moderate to severe exacerbations. Using meta-regression analysis, a model was generated with dFEV as the moderator variable and the absolute difference in exacerbation rate (RD), ratio of exacerbation rates (RRs), or hazard ratio (HR) as dependent variables.
RESULTS
The analysis of RD and RR included 119,227 patients, and the HR analysis included 73,475 patients. For every 100-mL change in predose FEV, the HR decreased by 21% (95% CI, 17-26; P < .001; R = 0.85) and the absolute exacerbation rate decreased by 0.06 per patient per year (95% CI, 0.02-0.11; P = .009; R = 0.05), which corresponded to an RR of 0.86 (95% CI, 0.81-0.91; P < .001; R = 0.20). The relationship with exacerbation risk remained statistically significant across multiple subgroup analyses.
CONCLUSIONS
A significant correlation between increased FEV and lower COPD exacerbation risk suggests that airway patency is an important mechanism responsible for this effect.
Topics: Airway Resistance; Disease Progression; Forced Expiratory Volume; Humans; Pulmonary Disease, Chronic Obstructive; Regression Analysis; Risk
PubMed: 28483609
DOI: 10.1016/j.chest.2017.04.174 -
Sleep Medicine Reviews Dec 2017This review aimed to determine the effectiveness of positional modification techniques in preventing supine sleep, sleep-disordered breathing and other clinically... (Meta-Analysis)
Meta-Analysis Review
This review aimed to determine the effectiveness of positional modification techniques in preventing supine sleep, sleep-disordered breathing and other clinically important outcomes in patients with supine obstructive sleep apnea (OSA). Randomized controlled trials comparing positional modification techniques with any other therapy or placebo were included. Electronic searches of databases including CENTRAL, MEDLINE, CINAHL, Embase, and Web of Science up to April 2016 were performed. Meta-analysis was undertaken where possible. This comprehensive meta-analysis found benefit for positional modification techniques in those with supine OSA in terms of reduction in apnea-hypopnea index (AHI) and time spent supine. Whilst positional modification techniques were effective in terms of a reduction in AHI, continuous positive airway pressure (CPAP) was more effective than these techniques. A reliable diagnosis of supine OSA should be considered, and further research is required on patient-centred outcomes including comfort, barriers to adherence, cost-analysis, and long term outcomes including the effect on cardiovascular disease, the metabolic syndrome, and insulin resistance.
Topics: Continuous Positive Airway Pressure; Humans; Posture; Randomized Controlled Trials as Topic; Sleep Apnea, Obstructive; Supine Position
PubMed: 28012784
DOI: 10.1016/j.smrv.2016.11.004 -
European Journal of Internal Medicine Apr 2017The study assessed the effect of continuous positive airway pressure (CPAP) therapy on the risk of developing type 2 diabetes by evaluating change in the homeostasis... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
The study assessed the effect of continuous positive airway pressure (CPAP) therapy on the risk of developing type 2 diabetes by evaluating change in the homeostasis model assessment of insulin resistance (HOMA-IR) fasting blood glucose (FBG) and fasting insulin following CPAP treatment in non-diabetic patients and pre-diabetic with obstructive sleep apnea (OSA).
METHODS
Medline, PubMed, Cochrane, and EMBASE databases were searched until August 24, 2015. The analysis included randomized controlled trials (RCTs), two arm prospective studies, cohort studies, and retrospective studies. The primary outcome measure was change of HOMA-IR in pre-diabetic patients receiving CPAP treatment.
RESULTS
Twenty-three studies were included with 965 patients who had OSA. Nineteen studies were prospective studies and four were RCTs. CPAP therapy resulted in a significant reduction in the pooled standard difference in means of HOMA-IR (-0.442, P=0.001) from baseline levels compared with the control group. Change in FBG and fasting insulin from baseline levels was similar for the CPAP and control groups. For RCT studies (n=4), there was no difference in change in HOMA-IR or FBG levels from baseline between CPAP and control groups. The combined effect of RCTs showed that CPAP was associated with a significant reduction in change from baseline in fasting insulin than the control group (standardized diff. in means between groups=-0.479, P value=0.003).
CONCLUSION
These findings support the use of CPAP in non-diabetic and pre-diabetic patients with OSA to reduce change of HOMA-IR and possibly reduce the risk of developing type 2 diabetes in this patient population.
Topics: Blood Glucose; Continuous Positive Airway Pressure; Diabetes Mellitus, Type 2; Humans; Insulin; Insulin Resistance; Prediabetic State; Randomized Controlled Trials as Topic; Sleep Apnea, Obstructive
PubMed: 27914881
DOI: 10.1016/j.ejim.2016.11.010 -
The Cochrane Database of Systematic... Oct 2016Many treatments for the common cold exist and are sold over-the-counter. Nevertheless, evidence on the effectiveness and safety of nasal decongestants is limited. (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Many treatments for the common cold exist and are sold over-the-counter. Nevertheless, evidence on the effectiveness and safety of nasal decongestants is limited.
OBJECTIVES
To assess the efficacy, and short- and long-term safety, of nasal decongestants used in monotherapy to alleviate symptoms of the common cold in adults and children.
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL, Issue 6, June 2016), which contains the Cochrane Acute Respiratory Infections (ARI) Specialised Register, MEDLINE (1946 to July 2016), Embase (2010 to 15 July 2016), CINAHL (1981 to 15 July 2016), LILACS (1982 to July 2016), Web of Science (1955 to July 2016) and clinical trials registers.
SELECTION CRITERIA
Randomised controlled trials (RCTs) and cluster-RCTs investigating the effectiveness and adverse effects of nasal decongestants compared with placebo for treating the common cold in adults and children. We excluded quasi-RCTs.
DATA COLLECTION AND ANALYSIS
Three review authors independently extracted and summarised data on subjective measures of nasal congestion, overall patient well-being score, objective measures of nasal airway resistance, adverse effects and general recovery. One review author acted as arbiter in cases of disagreement. We categorised trials as single and multi-dose and analysed data both separately and together. We also analysed studies using an oral or topical nasal decongestant separately and together.
MAIN RESULTS
We included 15 trials with 1838 participants. Fourteen studies included adult participants only (aged 18 years and over). In six studies the intervention was a single dose and in nine studies multiple doses were used. Nine studies used pseudoephedrine and three studies used oxymetazoline. Other decongestants included phenylpropanolamine, norephedrine and xylometazoline. Phenylpropanolamine (or norephedrine) is no longer available on the market therefore we did not include the results of these studies in the meta-analyses. Eleven studies used oral decongestants; four studies used topical decongestants.Participants were included after contracting the common cold. The duration of symptoms differed among studies; in 10 studies participants had symptoms for less than three days, in three studies symptoms were present for less than five days, one study counted the number of colds over one year, and one study experimentally induced the common cold. In the single-dose studies, the effectiveness of a nasal decongestant was measured on the same day, whereas the follow-up in multi-dose studies ranged between one and 10 days.Most studies were conducted in university settings (N = eight), six at a specific university common cold centre. Three studies were conducted at a university in collaboration with a hospital and two in a hospital only setting. In two studies the setting was unclear.There were large differences in the reporting of outcomes and the reporting of methods in most studies was limited. Therefore, we judged most studies to be at low or unclear risk of bias. Pooling was possible for a limited number of studies only; measures of effect are expressed as standardised mean differences (SMDs). A positive SMD represents an improvement in congestion. There is no defined minimal clinically important difference for measures of subjective improvement in nasal congestion, therefore we used the SMDs as a guide to assess whether an effect was small (0.2 to 0.49), moderate (0.5 to 0.79) or large (≥ 0.8).Single-dose decongestant versus placebo: 10 studies compared a single dose of nasal decongestant with placebo and their effectiveness was tested between 15 minutes and 10 hours after dosing. Seven of 10 studies reported subjective symptom scores for nasal congestion; none reported overall patient well-being. However, pooling was not possible due to the large diversity in the measurement and reporting of symptoms of congestion. Two studies recorded adverse events. Both studies used an oral decongestant and each of them showed that there was no statistical difference between the number of adverse events in the treatment group versus the placebo group.Multi-dose decongestant versus placebo: nine studies compared multiple doses of nasal decongestants with placebo, but only five reported on the primary outcome, subjective symptom scores for nasal congestion. Only one study used a topical decongestant; none reported overall patient well-being. Subjective measures of congestion were significantly better for the treatment group compared with placebo approximately three hours after the last dose (SMD 0.49, 95% confidence interval (CI) 0.07 to 0.92; P = 0.02; GRADE: low-quality evidence). However, the SMD of 0.49 only indicates a small clinical effect. Pooling was based on two studies, one oral and one topical, therefore we were unable to assess the effects of oral and topical decongestants separately. Seven studies reported adverse events (six oral and one topical decongestant); meta-analysis showed that there was no statistical difference between the number of adverse events in the treatment group (125 per 1000) compared to the placebo group (126 per 1000). The odds ratio (OR) for adverse events in the treatment group was 0.98 (95% CI 0.68 to 1.40; P = 0.90; GRADE: low-quality evidence). The results remained the same when we only considered studies using an oral decongestant (OR 0.95, 95% CI 0.65 to 1.39; P = 0.80; GRADE: low-quality evidence).
AUTHORS' CONCLUSIONS
We were unable to draw conclusions on the effectiveness of single-dose nasal decongestants due to the limited evidence available. For multiple doses of nasal decongestants, the current evidence suggests that these may have a small positive effect on subjective measures of nasal congestion in adults with the common cold. However, the clinical relevance of this small effect is unknown and there is insufficient good-quality evidence to draw any firm conclusions. Due to the small number of studies that used a topical nasal decongestant, we were also unable to draw conclusions on the effectiveness of oral versus topical decongestants. Nasal decongestants do not seem to increase the risk of adverse events in adults in the short term. The effectiveness and safety of nasal decongestants in children and the clinical relevance of their small effect in adults is yet to be determined.
Topics: Administration, Intranasal; Adult; Child; Common Cold; Humans; Imidazoles; Nasal Decongestants; Oxymetazoline; Phenylpropanolamine; Pseudoephedrine; Randomized Controlled Trials as Topic; Time Factors
PubMed: 27748955
DOI: 10.1002/14651858.CD009612.pub2 -
European Archives of... Mar 2017The objective of this study is to highlight the importance of anatomical and not-anatomical factors' identification for customized therapy in OSAHS patients. The data... (Review)
Review
The objective of this study is to highlight the importance of anatomical and not-anatomical factors' identification for customized therapy in OSAHS patients. The data sources are: MEDLINE, The Cochrane Library and EMBASE. A systematic review was performed to identify studies that analyze the role of multiple interacting factors involved in the OSAHS pathophysiology. 85 out of 1242 abstracts were selected for full-text review. A variable combinations pathophysiological factors contribute to realize differentiated OSAHS phenotypes: a small pharyngeal airway with a low resistance to collapse (increased critical closing pressure), an inadequate responses of pharyngeal dilator muscles (wakefulness drive to breathe), an unstable ventilator responsiveness to hypercapnia (high loop gain), and an increased propensity to wake related to upper airway obstruction (low arousal threshold). Identifying if the anatomical or not-anatomical factors are predominant in each OSAHS patient represents the current challenge in clinical practice, moreover for the treatment decision-making. In the future, if a reliable and accurate pathophysiological pattern for each OSAHS patient can be identified, a customized therapy will be feasible, with a significant improvement of surgical success in sleep surgery and a better understanding of surgical failure.
Topics: Disease Management; Humans; Patient Care Planning; Pharynx; Sleep; Sleep Apnea, Obstructive
PubMed: 27470114
DOI: 10.1007/s00405-016-4223-y -
JAMA Facial Plastic Surgery Sep 2016The internal nasal valve is the narrowest part of the nasal airway and a common site of inspiratory collapse and obstruction of nasal airflow. Over-the-counter... (Comparative Study)
Comparative Study Review
IMPORTANCE
The internal nasal valve is the narrowest part of the nasal airway and a common site of inspiratory collapse and obstruction of nasal airflow. Over-the-counter mechanical nasal dilators are an alternative to surgical intervention that attempts to improve airflow through the internal nasal valve.
OBJECTIVE
To determine the efficacy of over-the-counter mechanical nasal dilators and classify these products by mechanism.
EVIDENCE REVIEW
A database of 33 available over-the-counter mechanical nasal dilators was generated via a PubMed search as well as an internet search via Amazon.com and Google, conducted from April 1, 2013, through December 31, 2015. Products determined to be unavailable or discontinued were excluded from the database. Of the devices examined in published literature, efficacy was based on objective measures, such as measured airflow, the cross-sectional area of the nasal valve, and changes in resistance. Measures of reported sleep quality or patient perception were excluded.
FINDINGS
An analysis of each product's mechanism revealed 4 broad classes: external nasal dilator strips, nasal stents, nasal clips, and septal stimulators. A review demonstrated 5 studies supporting the use of external nasal dilator strips, 4 studies supporting the use of nasal clips, 1 study supporting the use of nasal stents, and no studies supporting the use of septal stimulators.
CONCLUSIONS AND RELEVANCE
Our findings suggest that external nasal dilator strips and nasal clips effectively relieve obstruction of the internal nasal valve and may be an alternative to surgical intervention in some patients.
Topics: Airway Resistance; Dilatation; Humans; Nasal Obstruction
PubMed: 27367589
DOI: 10.1001/jamafacial.2016.0291