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Health Technology Assessment... Jan 2009To review the evidence on the clinical effects and associated treatment costs of surgical procedures and non-surgical devices for the management of non-apnoeic snoring. (Meta-Analysis)
Meta-Analysis Review
OBJECTIVES
To review the evidence on the clinical effects and associated treatment costs of surgical procedures and non-surgical devices for the management of non-apnoeic snoring.
DATA SOURCES
Major electronic databases were searched for relevant studies published between 1980 and 2007. All treatment costs were estimated based on data from NHS reference costs, device manufacturers and clinical opinion.
REVIEW METHODS
Studies were screened, data extracted and quality assessed according to standard methods. Results were broadly grouped according to the intervention and comparator when applicable, and further subgrouped according to the specific intervention type and study design. Results were combined using a narrative synthesis with relevant quantitative results tabulated. Differences between studies assessing the same intervention were explored narratively by examining differences in the intervention, study duration and study quality.
RESULTS
The systematic review included 27 studies (three randomised controlled trials, two controlled clinical trials and 22 pre-post studies) reported in 30 publications assessing uvulopalatopharyngoplasty (UP3) versus laser-assisted uvulopalatoplasty (LAUP), UP3 alone, LAUP alone, palatal stiffening techniques (Pillar implants and injection snoreplasty), radiofrequency ablation (RFA) of the soft palate or tongue base, continuous positive airway pressure (CPAP) devices and mandibular advancement splints (MAS). Studies were generally of a low methodological quality with small sample sizes. A total of 1191 patients was included. Both UP3 and LAUP reduced the number of snores per hour and produced a modest reduction in snoring loudness. UP3 was effective in reducing a number of subjectively reported snoring indices, but results on objective measures were equivocal. Limited evidence indicates that subjectively assessed snoring is improved after LAUP; no objective measures were assessed. RFA was associated with a reduction in partner-assessed snoring intensity, though evidence for an objective reduction in snoring sound levels was mixed. Pillar implants were moderately effective at reducing partner-rated snoring intensity, but had no effect on objective snoring indices. Use of CPAP reduced the number of snores per hour; no subjective measures were evaluated. Use of MAS improved objective snoring outcomes, including the maximal snoring sound volume, the mean snoring sound volume and the percentage of time spent in loud snoring; no subjective measures were evaluated. The cost for UP3 ranges from approximately 1230 pounds to approximately 1550 pounds. For LAUP the cost varies from 790 pounds to 2070 pounds depending on the number of stages of the procedure. The treatment costs associated with the use of Pillar implants range from 1110 pounds to 1160 pounds. The approximate annual treatment costs associated with the use of a CPAP machine and MAS are 220 pounds and 130 pounds respectively.
CONCLUSIONS
This study highlighted the paucity and poor quality of the evidence available on the effects of both surgical procedures and non-surgical devices for the management of primary snoring. Any conclusions to be drawn from the results are therefore somewhat tentative. There was no procedure that was clearly the least-cost option. Further research should focus on standardising methods of measuring outcomes and reporting, undertaking active controlled trials, and investigating the longer-term effects of treatments.
Topics: Airway Obstruction; Cost-Benefit Analysis; Equipment and Supplies; Health Care Costs; Humans; Laser Therapy; Pharynx; Snoring; Technology Assessment, Biomedical; Treatment Outcome; Uvula; Velopharyngeal Sphincter
PubMed: 19091167
DOI: 10.3310/hta13030 -
Biomedicines Sep 2022Obstructive sleep apnoea (OSA) affects patients' quality of life and health. Magnesium (Mg) is an essential mineral and a potent antioxidant. Mg deficiency can worsen... (Review)
Review
Obstructive sleep apnoea (OSA) affects patients' quality of life and health. Magnesium (Mg) is an essential mineral and a potent antioxidant. Mg deficiency can worsen oxidative stress caused by sleep deprivation or disorders. The impact of OSA on serum Mg levels and its health consequences remain unclear. This study systematically reviewed clinical studies investigating the serum Mg levels of OSA patients and the potential relationships with other biomarkers. Six articles were included for qualitative synthesis and quantitative analysis. Two out of four studies that compared OSA patients to healthy controls found them to have significantly lower serum Mg levels. Our meta-analysis with three studies shows that patients with OSA had significantly lower serum Mg with an effect size of -1.22 (95% CI: -2.24, -0.21). However, the mean serum Mg level of OSA patients ( = 251) pooled from five studies (1.90 mg/dL, 95% CI: 1.77, 2.04) does not differ significantly from the normal range between 1.82 to 2.30 mg/dL. OSA severity appears to affect serum Mg negatively. Serum Mg levels generally improve after treatment, coinciding with the improvement of OSA severity. Low serum Mg levels correlate with the worsening of cardiovascular risk biomarkers of C-reactive protein, ischaemia-modified albumin, and carotid intima-media thickness. The serum Mg levels also potentially correlate with biomarkers for lipid profile, glucose metabolism, calcium, and heavy metals. Sleep deprivation appears to deplete Mg levels of OSA patients, making them at risk of Mg deficiency, which potentially increases systemic inflammation and the risk of cardiovascular and metabolic diseases.
PubMed: 36140382
DOI: 10.3390/biomedicines10092273 -
Revista Portuguesa de Cardiologia :... May 2024Obstructive sleep apnea (OSA) is one of the main risk factors for cardiovascular diseases and is associated with both morbidity and mortality. OSA has also been linked... (Review)
Review
INTRODUCTION
Obstructive sleep apnea (OSA) is one of the main risk factors for cardiovascular diseases and is associated with both morbidity and mortality. OSA has also been linked to arrhythmias and sudden death.
OBJECTIVE
To assess whether OSA increases the risk of sudden death in the non-cardiac population.
METHODS
This is a systematic review of the literature. The descriptors "sudden death" and "sleep apnea" and "tachyarrhythmias" and "sleep apnea" were searched in the PubMed/Medline and SciELO databases.
RESULTS
Thirteen articles that addressed the relationship between OSA and the development of tachyarrhythmias and/or sudden death with prevalence data, electrocardiographic findings, and a relationship with other comorbidities were selected. The airway obstruction observed in OSA triggers several systemic repercussions, e.g., changes in intrathoracic pressure, intermittent hypoxia, activation of the sympathetic nervous system and chemoreceptors, and release of catecholamines. These mechanisms would be implicated in the appearance of arrhythmogenic factors, which could result in sudden death.
CONCLUSION
There was a cause-effect relationship between OSA and cardiac arrhythmias. In view of the pathophysiology of OSA and its arrhythmogenic role, studies have shown a higher risk of sudden death in individuals who previously had heart disease. On the other hand, there is little evidence about the occurrence of sudden death in individuals with OSA and no heart disease, and OSA is not a risk factor for sudden death in this population.
Topics: Humans; Arrhythmias, Cardiac; Death, Sudden; Risk Factors; Sleep Apnea Syndromes; Sleep Apnea, Obstructive
PubMed: 38309430
DOI: 10.1016/j.repc.2024.01.003 -
Critical Care Medicine Feb 2014Inhaled anticoagulation regimens are increasingly being used to manage smoke inhalation-associated acute lung injury. We systematically reviewed published and... (Review)
Review
OBJECTIVE
Inhaled anticoagulation regimens are increasingly being used to manage smoke inhalation-associated acute lung injury. We systematically reviewed published and unpublished preclinical and clinical trial data to elucidate the effects of these regimens on lung injury severity, airway obstruction, ventilation, oxygenation, pulmonary infections, bleeding complications, and survival.
DATA SOURCES
PubMed, Scopus, EMBASE, and Web of Science were searched to identify relevant published studies. Relevant unpublished studies were identified by searching the Australian and New Zealand Clinical Trials Registry, World Health Organization International Clinical Trials Registry Platform, Cochrane Library, ClinicalTrials.gov, MINDCULL.com, Current Controlled Trials, and Google.
STUDY SELECTION
Inclusion criteria were any preclinical or clinical study in which 1) animals or subjects experienced smoke inhalation exposure, 2) they were treated with nebulized or aerosolized anticoagulation regimens, including heparin, heparinoids, antithrombins, or fibrinolytics (e.g., tissue plasminogen activator), 3) a control and/or sham group was described for preclinical studies, and 4) a concurrent or historical control group described for clinical studies. Exclusion criteria were 1) the absence of a group treated with a nebulized or aerosolized anticoagulation regimen, 2) the absence of a control or sham group, and 3) case reports.
DATA EXTRACTION
Ninety-nine potentially relevant references were identified. Twenty-seven references met inclusion criteria including 19 preclinical references reporting 18 studies and eight clinical references reporting five clinical studies.
DATA SYNTHESIS
A systematic review of the literature is provided. Both clinical and methodological diversity precluded combining these studies in a meta-analysis.
CONCLUSIONS
The high mortality associated with smoke inhalation-associated acute lung injury results from airway damage, mucosal dysfunction, neutrophil infiltration, airway coagulopathy with cast formation, ventilation-perfusion mismatching with shunt, and barotrauma. Inhaled anticoagulation regimens in both preclinical and clinical studies improve survival and decrease morbidity without altering systemic markers of clotting and anticoagulation. In some preclinical and clinical studies, inhaled anticoagulants were associated with a favorable effect on survival. This approach appears sufficiently promising to merit a well-designed prospective study to validate its use in patients with severe smoke inhalation-associated acute lung injury requiring mechanical ventilation.
Topics: Acute Lung Injury; Administration, Inhalation; Anticoagulants; Humans; Smoke Inhalation Injury
PubMed: 24158173
DOI: 10.1097/CCM.0b013e3182a645e5 -
The Cochrane Database of Systematic... Sep 2015Bronchiolitis is the leading cause of hospitalisation among infants in high-income countries. Acute viral bronchiolitis is associated with airway obstruction and... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Bronchiolitis is the leading cause of hospitalisation among infants in high-income countries. Acute viral bronchiolitis is associated with airway obstruction and turbulent gas flow. Heliox, a mixture of oxygen and the inert gas helium, may improve gas flow through high-resistance airways and decrease the work of breathing. In this review, we selected trials that objectively assessed the effect of the addition of heliox to standard medical care for acute bronchiolitis.
OBJECTIVES
To assess heliox inhalation therapy in addition to standard medical care for acute bronchiolitis in infants with respiratory distress, as measured by clinical endpoints (in particular the rate of endotracheal intubation, the rate of emergency department discharge, the length of treatment for respiratory distress) and pulmonary function testing (mainly clinical respiratory scores).
SEARCH METHODS
We searched CENTRAL (2015, Issue 2), MEDLINE (1966 to March week 3, 2015), EMBASE (1974 to March 2015), LILACS (1982 to March 2015) and the National Institutes of Health (NIH) website (May 2009).
SELECTION CRITERIA
Randomised controlled trials (RCTs) and quasi-RCTs of heliox in infants with acute bronchiolitis.
DATA COLLECTION AND ANALYSIS
Two review authors independently extracted data and assessed trial quality.
MAIN RESULTS
We included seven trials involving 447 infants younger than two years with respiratory distress secondary to viral bronchiolitis. All children were recruited from a paediatric intensive care unit (PICU; 378 infants), except in one trial (emergency department; 69 infants). All children were younger than two (under nine months in two trials and under three months in one trial). Positive tests for respiratory syncytial virus (RSV) were required for inclusion in five trials. The two other trials were carried out in the bronchiolitis seasons. Seven different protocols were used for inhalation therapy with heliox.When heliox was used in the PICU, we observed no significant reduction in the rate of intubation: risk ratio (RR) 2.73 (95% confidence interval (CI) 0.96 to 7.75, four trials, 408 infants, low quality evidence). When heliox inhalation was used in the emergency department, we observed no increase in the rate of discharge: RR 0.51 (95% CI 0.17 to 1.55, one trial, 69 infants, moderate quality evidence).There was no decrease in the length of treatment for respiratory distress: mean difference (MD) -0.19 days (95% CI -0.56 to 0.19, two trials, 320 infants, moderate quality evidence). However, in the subgroup of infants who were started on nasal continuous positive airway pressure (nCPAP) right from the start, because of severe respiratory distress, heliox therapy reduced the length of treatment: MD -0.76 days (95% CI -1.45 to -0.08, one trial, 21 infants, low quality evidence). No adverse events related to heliox inhalation were reported.We found that infants treated with heliox inhalation had a significantly lower mean clinical respiratory score in the first hour after starting treatment when compared to those treated with air or oxygen inhalation: MD -1.04 (95% CI -1.60 to -0.48, four trials, 138 infants, moderate quality evidence). This outcome had statistical heterogeneity, which remained even after removing the study using a standard high-concentration reservoir mask. Several factors may explain this heterogeneity, including first the limited number of patients in each trial, and the wide differences in the baseline severity of disease between studies, with the modified Wood Clinical Asthma Score (m-WCAS) in infants treated with heliox ranging from less than two to more than seven.
AUTHORS' CONCLUSIONS
Current evidence suggests that the addition of heliox therapy may significantly reduce a clinical score evaluating respiratory distress in the first hour after starting treatment in infants with acute RSV bronchiolitis. We noticed this beneficial effect regardless of which heliox inhalation protocol was used. Nevertheless, there was no reduction in the rate of intubation, in the rate of emergency department discharge, or in the length of treatment for respiratory distress. Heliox could reduce the length of treatment in infants requiring CPAP for severe respiratory distress. Further studies with homogeneous logistics in their heliox application are needed. Inclusion criteria must include a clinical severity score that reflects severe respiratory distress to avoid inclusion of children with mild bronchiolitis who may not benefit from heliox inhalation. Such studies would provide the necessary information as to the appropriate place for heliox in the therapeutic schedule for severe bronchiolitis.
Topics: Acute Disease; Administration, Inhalation; Bronchiolitis, Viral; Bronchodilator Agents; Helium; Humans; Infant; Intensive Care Units, Pediatric; Intubation, Intratracheal; Length of Stay; Oxygen; Randomized Controlled Trials as Topic; Respiratory Syncytial Virus Infections
PubMed: 26384333
DOI: 10.1002/14651858.CD006915.pub3 -
Journal of Otolaryngology - Head & Neck... Dec 2023Juvenile Nasopharyngeal Angiofibroma (JNA) is a fibrovascular tumor of the nasopharynx that classically presents in adolescent males. The reported mean age of onset is... (Review)
Review
BACKGROUND
Juvenile Nasopharyngeal Angiofibroma (JNA) is a fibrovascular tumor of the nasopharynx that classically presents in adolescent males. The reported mean age of onset is between 13 and 22 years old [1-6]. Significant androgen stimulation is hypothesized to explain the strong predisposition for JNA to present in young adolescent males. However, considerable variability in age at diagnosis exists with rare involvement of very young patients incongruent with typical male pubertal growth patterns.
OBJECTIVE
The purpose of this systematic review is to identify cases of early-onset JNA (EOJNA), (defined as age < 10 years) in the literature and to examine the disease characteristics and treatments used in this patient group. A case of a 7 year old boy with EOJNA at our institution is also described and presented.
METHODS
We searched Embase, Cochrane database and MEDLINE from 1996 to February 2021 for studies that reported cases of EOJNA. Relevant clinico-demographic data, disease severity and treatment outcomes were recorded and analyzed using descriptive statistics. We compared our findings with reported means for JNA in all ages.
RESULTS
We identified 29 studies containing a total of 34 cases of EOJNA. The vast majority (31/34) of patients were males and the mean age of diagnosis was 8.15 years old. The most common presenting symptoms were nasal obstruction (65.2%) and epistaxis (60.9%). Patients were most commonly Radkowski stage II (39.4%) and III (39.4%). Primary treatment modalities included open surgery (66.7%), endoscopic surgery (24.2%), and radiotherapy (9.1%). Recurrence was evident in 30%. Radkowski stage and type of treatment did not differ significantly within the EOJNA group (p = 0.440 and p = 0.659, respectively).
CONCLUSION
This systematic review suggests that rare cases of EOJNA have distinct disease characteristics. Patients in this cohort appeared to have more advanced disease and higher recurrence rates when compared with reported averages. We hope that this review prompts increased clinical awareness of this potentially more aggressive subtype of JNA. As more cases of EOJNA are reported, a more powered statistical analysis of this cohort would be feasible.
Topics: Adolescent; Humans; Male; Young Adult; Adult; Child; Female; Angiofibroma; Nasopharyngeal Neoplasms; Epistaxis; Treatment Outcome; Nasal Obstruction; Retrospective Studies
PubMed: 38115030
DOI: 10.1186/s40463-023-00687-w -
Sleep Science (Sao Paulo, Brazil) 2022Obstructive sleep apnoea (OSA) is a common disorder marked by repetitive occurrence of breathing cessation during sleep due to partial or complete upper airway... (Review)
Review
Obstructive sleep apnoea (OSA) is a common disorder marked by repetitive occurrence of breathing cessation during sleep due to partial or complete upper airway obstruction. An obstructive airway and the successive asphyxia chronically overload the inspiratory muscles resulting in an increased inspiratory effort. The present systematic review aimed to examine the effects of inspiratory muscle training (IMT) on inspiratory muscle strength [maximal inspiratory pressure (PImax)], severity of disease [apnea hypopnoea index (AHI)], sleep quality [Pittsburgh sleep quality index (PSQI)], day time sleepiness [Epworth sleepiness scale (ESS)], lung function [forced expiratory volume in 1 second (FEV)] and exercise capacity [cardiopulmonary exercise testing, (CPET), 6 minute walk test, (6MWT)] in mild to severe OSA. Among 953 articles retrieved from various databases (PubMed, SCOPUS, Web of Science and Cochrane), 7 articles were found to be eligible for the present review. Randomized controlled trials reporting the effect of IMT in OSA were selected. The quality assessment was conducted using Cochrane risk-of-bias tool for randomized trials. All seven studies were meta-analyzed. The result depicted significant change in PImax, ES 1.73 (95%CI 0.54 to 2.92, =0.004), PSQI -1.29 (95%CI -1.94 to -0.65, <0.0001), ESS -1.08 (95% CI -1.79 to - 0.37, =0.003) and FEV 0.74 (95%CI 0.20 to 1.28, =0.007). IMT may be considered as an effective treatment strategy in mild to severe OSA resulting in improved inspiratory muscle strength, sleep quality, daytime sleepiness, and lung function. However, there is still dearth evidence on repercussion of IMT on lung function and exercise capacity and warrants high quality evidence to reach definitive conclusions.
PubMed: 36419804
DOI: 10.5935/1984-0063.20220081 -
The Cochrane Database of Systematic... Jan 2010Adenoidectomy, surgical removal of the adenoids, is a common ENT operation worldwide in children with recurrent or chronic nasal symptoms. A systematic review on the... (Review)
Review
BACKGROUND
Adenoidectomy, surgical removal of the adenoids, is a common ENT operation worldwide in children with recurrent or chronic nasal symptoms. A systematic review on the effectiveness of adenoidectomy in this specific group has not previously been performed.
OBJECTIVES
To assess the effectiveness of adenoidectomy versus non-surgical management in children with recurrent or chronic nasal symptoms.
SEARCH STRATEGY
We searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials (CENTRAL); PubMed; EMBASE; CINAHL; Web of Science; BIOSIS Previews; Cambridge Scientific Abstracts; mRCT and additional sources for published and unpublished trials. The date of the most recent search was 30 March 2009.
SELECTION CRITERIA
Randomised controlled trials comparing adenoidectomy, with or without tympanostomy tubes, versus non-surgical management or tympanostomy tubes alone in children with recurrent or chronic nasal symptoms. The primary outcome studied was the number of episodes, days per episode and per year with nasal symptoms and the proportion of children with recurrent episodes of nasal symptoms. Secondary outcomes were mean number of episodes, mean number of days per episode and per year, and proportion of children with nasal obstruction alone.
DATA COLLECTION AND ANALYSIS
Two authors assessed trial quality and extracted data independently.
MAIN RESULTS
Only one study included children scheduled for adenoidectomy because of recurrent or chronic nasal symptoms or middle ear disease. In this study no beneficial effect of adenoidectomy was found. The numbers in this study were, however, small (n = 76) and the quality of the study was moderate. The outcome was improvement in episodes of common colds. The risk differences were non-significant, being 2% (95% CI -18% to 22%) and -11% (95% CI -28% to 7%) after 12 and 24 months, respectively.A second study included children with recurrent acute otitis media (n = 180). As otitis media is known to be associated with nasal symptoms, the number of days with rhinitis was studied as a secondary outcome measure. The risk difference was non-significant, being -4 days (95% CI -13 to 7 days).
AUTHORS' CONCLUSIONS
Current evidence regarding the effect of adenoidectomy on recurrent or chronic nasal symptoms or nasal obstruction alone is sparse, inconclusive and has a significant risk of bias.High quality trials assessing the effectiveness of adenoidectomy in children with recurrent or chronic nasal symptoms should be initiated.
Topics: Adenoidectomy; Adolescent; Child; Chronic Disease; Humans; Nasal Obstruction; Otitis Media with Effusion; Otitis Media, Suppurative; Randomized Controlled Trials as Topic; Recurrence; Tympanic Membrane
PubMed: 20091663
DOI: 10.1002/14651858.CD008282 -
European Respiratory Review : An... Dec 2023Robin sequence (RS), a congenital disorder of jaw maldevelopment and glossoptosis, poses a substantial healthcare burden and has long-term health implications if airway... (Meta-Analysis)
Meta-Analysis Review
Robin sequence (RS), a congenital disorder of jaw maldevelopment and glossoptosis, poses a substantial healthcare burden and has long-term health implications if airway obstruction is suboptimally treated. This study describes the global birth prevalence of RS and investigates whether prevalence estimates differ by geographical location, ethnicity or study data source (registry non-registry data). The protocol was prospectively registered with PROSPERO.Databases were searched using keywords and subject terms for "Robin sequence", "epidemiology", "incidence" and "birth prevalence". Meta-analysis was performed fitting random effects models with arcsine transformation.From 34 eligible studies (n=2722 RS cases), pooled birth prevalence was 9.5 per 100 000 live births (95% CI 7.1-12.1) with statistical heterogeneity. One third of studies provided a case definition for RS and numerous definitions were used. A total of 22 countries were represented, predominantly from European populations (53% of studies). There was a trend towards higher birth prevalence in European populations and lower prevalence from registry-based studies. Only two studies reported ethnicity.This study indicates that RS occurs globally. To investigate geographical differences in prevalence, additional studies from non-European populations and reporting of ethnicity are needed. Heterogeneity of estimates may be due to variable diagnostic criteria and ascertainment methods. Recently published consensus diagnostic criteria may reduce heterogeneity among future studies.
Topics: Infant; Humans; Pierre Robin Syndrome; Prevalence; Incidence; Registries; Consensus
PubMed: 38056889
DOI: 10.1183/16000617.0133-2023 -
Sleep Medicine Reviews Jun 2021Multilevel surgery (MLS) and maxillomandibular advancement surgery (MMA) are two established options in surgical management of obstructive sleep apnea (OSA), which... (Meta-Analysis)
Meta-Analysis Review
Multilevel surgery (MLS) and maxillomandibular advancement surgery (MMA) are two established options in surgical management of obstructive sleep apnea (OSA), which target different levels of airway obstruction. The objective of this review was to comparatively evaluate the clinical efficacy and safety of MMA and MLS in the treatment of OSA. MEDLINE and Embase databases were searched for studies on MMA and/or MLS in OSA patients. Twenty MMA studies and 39 MLS studies were identified. OSA patients who underwent MMA showed significant improvements in AHI, LSAT, ODI, and ESS by -46.2/h, 13.5%, -30.3/h, and -8.5, respectively. The pooled rates of surgical success and cure for MMA were 85.0% and 46.3%, respectively. Patients who underwent MLS showed significant improvements in AHI, LSAT, ODI, and ESS by -24.7/h, 8.7%, -19.1/h, and -5.8, respectively. The pooled surgical success and cure rates for MLS were 65.1% and 28.1%, respectively. The rates of major complication of MMA and MLS were 3.2% and 1.1%, respectively, and the rate of minor complication of MMA was higher than that of MLS. We conclude that both MMA and MLS are effective treatment options for OSA. Compared to MLS, MMA may be more effective in improving OSA. However, the complication rate of MMA is higher.
Topics: Humans; Mandibular Advancement; Sleep Apnea, Obstructive; Treatment Outcome
PubMed: 33831676
DOI: 10.1016/j.smrv.2021.101471