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Clinical article

Zeroing in on positional obstructive sleep apnea

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Continuing to examine positional obstructive sleep apnea in-depth

Positional obstructive sleep apnea, or positional OSA (POSA), is highly prevalent1 and requires long-term management. A clinical subtype of OSA, it is similar in all essential aspects other than that respiratory events occur primarily during supine sleep. 

Supine sleep icon

50%

Determine if 50% of more of apneas and hypopneas happen during supine sleep. It is also useful to know the non-supine AHI.

Relieving symptoms

 

Sleep positional therapy reduces sleep in a supine position and is one of the most common medical recommendations given to patients with positional OSA (POSA). Sleep positional therapy devices have been shown to decrease time spent sleeping supine, apnea hypopnea index (AHI) and oxygen desaturation index (ODI), and reduce daytime sleepiness, with these benefits persisting over time.2 

Diagnosing positional OSA (POSA)3,4

 

A simple two-step approach can be used to identify positional OSA (POSA). First, look at the total AHI in the sleep study report to establish that it is at least 5 events per hour. Then, determine if 50% of more of apneas and hypopneas happen during supine sleep. It is also useful to know the non-supine AHI. Most sleep study reports regularly provide the positional OSA (POSA) index. 

53 percent icon
POSA is highly prevalent. In middle-to older age adults.

53%

POSA was present in 53% of all individuals.

26%

More inportantly, exlusive POSA (when non-supine AHI is normal) was present in 26% of all persons, and 36% of OSA patients.1

75%

POSA was present in 75% of OSA patients.

36%

Exclusive POSA was present in 36% of OSA patients.1
Blue #1 circle icon

Positional OSA (POSA) is highly prevalent.

 

In middle-to-older age adults, positional OSA (POSA) was present in 53% of all individuals, and in 75% of OSA patients. More importantly, exclusive positional OSA (POSA) (when non-supine AHI is normal) was present in 26% of all persons, and in 36% of OSA patients.1

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Sleep position can influence the classification of OSA severity.

 

6% of patients without OSA and 30% with mild OSA based on AHI would be classified as moderate-to-severe if they had slept only supine.5

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Self-reports of supine sleep position are unreliable. 

 

When asked to predict their sleep position, 80% of patients misjudged the extent of their supine sleep, and the proportion of supine sleep was underestimated by 21.6%.6

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Positional OSA (POSA) patients are different.

 

They tend to be younger than non-positional OSA patients, and have a lower body mass index, neck and waist circumference, and prevalence of hypertension.7

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Positional OSA (POSA) may be undertreated.

 

Using home sleep apnea testing, investigators noted that 54.6% of OSA are positional. Positional OSA (POSA) patients were less likely to receive CPAP therapy.8

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Positional sleep therapy is commonly recommended.

 

In addition to weight management, positional therapy is commonly advised.9

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Effectiveness for different positional OSA (POSA)  treatment strategies varies.

 

The sleep position trainer (SPT) was more effective in improving sleep quality and quality of life and had higher compliance at 1 month compared to the tennis ball technique.10

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Positional sleep apnea therapy and CPAP are equally effective in improving AHI to less than 5 events per hour in positional OSA (POSA) patients.

 

In 38 patients with positional OSA (POSA), AHI decreased to less than 5 in 92%, and 97% with positional sleep therapy and CPAP, respectively (p=0.16).11

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Efficacy of positional OSA (POSA) therapy is comparable to oral devices.

 

The SPT was compared to oral appliance therapy in patients with mild to moderate positional OSA (POSA) (AHI 5–30). Median AHI decreased significantly at 12 months in the SPT group and was not different compared to oral  appliance therapy. Adherence was similar between the two treatment groups.12

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Positional OSA (POSA) therapy provides benefits post-upper-airway surgery.

 

The SPT was also studied in patients with residual positional OSA (POSA) after upper-airway surgery. Adding SPT therapy resulted in a 31% treatment success at 3 months; compliance rate with SPT was 89%.13

Conclusion

Keep these findings in mind when assessing patients for possible positional OSA (POSA). Early diagnosis and appropriate therapy can help them regain better sleep and a better quality of life. 

 

Given the prevalence of positional OSA (POSA) and its potential long-term impact on quality of life, the Sleep and Respiratory Newsletter will continue its focus on the diagnostic and therapeutic treatment strategies for positional OSA (POSA) throughout the year.

For further in-depth information, view the abstract by Heinzer R, et al. Prevalence and characteristics of positional sleep apnea in the HypnoLaus population-based cohort. J Sleep Med. 2018 Aug;48:157-162.

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1. Heinzer R, et al. J Sleep Med. 2018 Aug;48:157-162. 

2. van Maanen et al. Sleep. 2014 July 1;37(7):1209-15.

3. Oksenberg A et al. J Sleep Res. 2014 Apr;23(2):204-10.

4. Morong S et al. Sleep Breath. 2014 Mar;18(1):31-7. 

5. Sunnergren O, et al. Sleep Breath. 2013 Mar;17(1):173-9.

6. Sorscher AJ, et al. Sleep Breath. 2018 Sep;22(3):625-630. 

7. Oulhaj A, et al. Sleep Breath. 2017 Dec;21(4):877-884.

8. Di-Tullio F, et al. Sleep Sci. 2018 Jan-Feb;11(1):8-11. 

9. Jackson M, et al. Sleep Med. 2015 Apr;16(4):545-52. 

10. Eijsvogel MM, et al. J Clin Sleep Med. 2015 Jan 15;11(2):139-47. 

11. Permut I, et al. J Clin Sleep Med. 2010 Jun 15;6(3):238-43.

12. de Ruiter MHT, et al. Sleep Breath. 2018 May;22(2):441-450.      

13. Benoist LBL, et al. Sleep Breath. 2017 May;21(2):279-288