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Rethinking positional obstructive sleep apnea management

A recent study in the Journal of Clinical Sleep Medicine shows that the Philips NightBalance SPT is non-inferior to traditional auto-CPAP therapy.12

Successfully managing sleep patients in today’s changing healthcare environment is more challenging and costly than ever. 


It has become increasingly important to diagnose complex sleep conditions more efficiently, make therapy easier for patients to live with and make ongoing care more productive and cost-effective.


Take positional obstructive sleep apnea (POSA): Published criteria allow people with POSA to be identified from a sleep study.1 But its prevalence may be underestimated, perhaps because the same sleep therapy has traditionally been used for all kinds of OSA.


It’s time to start looking at POSA more closely, not only rethinking assumptions about diagnosis, but also to taking a fresh look at positional therapy devices. One such device is now backed by clinical evidence. We’ve come a long way since the tennis ball technique of treating POSA.

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The POSA patient profile

POSA is commonly defined as a total apnea-hypopnea index (AHI) ≥ 5 and a ratio supine AHI to non-supine AHI of ≥ 2.1  A recent study by Heinzer, et al., (2018), demonstrates that exclusive POSA was present in 36–47% of OSA subjects.2


POSA patients tend to be younger, with lower body mass index (BMI) and neck and waist circumference, as compared to non-POSA patients. Berlin and STOP scores and prevalence of hypertension were also lower.2


Generally, 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%.3

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Positional therapy Is effective

Positional therapy, along with weight management, is one of the most commonly used methods for treating POSA. Many sleep position trainer devices are available prevent supine sleep, including the low-tech tennis ball approach—tennis balls placed in a pocket sewn over the back of a nightshirt. When the patient starts to roll over on his back, the tennis balls are an unpleasant prompt. No wonder long-term compliance with the tennis ball technique is poor (in one study, 6% at 2–3 years).4

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On the other hand, the same study showed that short-term adherence to the sleep position trainer was high (75% to 95%).5


These devices are much more readily accepted by patients; are more effective in reducing AHI; improving sleep quality and quality of life; and have a higher compliance at one month compared to the tennis ball technique.6


Further, positional therapy devices have been shown to decrease time spent supine, AHI, oxygen desaturation index, and Epworth Sleepiness Scale, with these benefits persisting over time.7

Backed by clinical evidence

The new NightBalance sleep position trainer device from Philips is backed by clinical evidence:

To adults diagnosed with mild to moderate positional obstructive sleep apnea, the NightBalance technology delivers a long-term improvement in sleep quality.8

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of adults using the NightBalance therapy reported a decrease in the number of breathing interruptions, gasping and/or choking during the night.9

A word about gender differences in managing obstructive sleep apnea…

Infograph OSA in women

In diagnosing for OSA in women, keep in mind that traditional screening tools, such as the STOP-Bang, might miss many women because their symptoms are different from men’s.

Generally, they report less snoring and witnessed apneas and present more often with non-specific symptoms of insomnia, fatigue, sleepiness, morning headaches, and mood disturbances.


In addition, sleep study findings for women tend to be different, with less oxygen desaturation, less supine position dependency, and lower AHI, as compared to men with similar BMI.10


OSA is less common in pre-menopausal women than in men, but the risk of OSA increases among pregnant women and women during menopause.

…and a call to action


It is critical to consider these gender-related differences during sleep studies to accurately diagnose the presence of sleep-disordered breathing. The stakes are higher for women because they have increased risk of hypertension, endothelial dysfunction, arterial stiffness, coronary calcium score and cardiovascular death.11


Understanding the gender differences in symptoms and outcomes of OSA will allow health professional to more effectively screen, diagnoses and manage women with sleep disordered breathing.

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1, 2 Discriminating between positional and non-positional obstructive sleep apnea using some clinical characteristics. Oulhaj A, Al Dhaheri S, Su BB, Al-Houqani M. Sleep Breath. 2017 Dec;21(4):877-884.

3 Patient-predicted sleep position vs. HST data: a tendency to underestimate supine sleep. Sorscher AJ, Anzivino AP, Mackenzie T. Sleep Breath. 2018 Sep;22(3):625-630.

4 Poor long-term patient compliance with the tennis ball technique for treating positional obstructive sleep apnea. Bignold JJ, Deans-Costi G, Goldsworthy MR, Robertson CA, McEvoy D, Catcheside PG, Mercer JD. J Clin Sleep Med. 2009 Oct 15;5(5):428-30.

5 Long-term effectiveness and compliance of positional therapy with the Sleep Position Trainer in the treatment of positional obstructive sleep apnea syndrome. van Maanen JP, de Vries N. SLEEP 2014;37(7):1209-1215.

6 Sleep position trainer versus tennis ball technique in positional obstructive sleep apnea syndrome. Eijsvogel MM, Ubbink R, Dekker J, Oppersma E, de Jongh FH, van der Palen J, Brusse-Keizer MG. J Clin Sleep Med. 2015 Jan 15;11(2):139-47.

7 van Maanen et al, Long-Term Effectiveness and Compliance of Positional Therapy with the Sleep Position Trainer in the Treatment of Positional Obstructive Sleep Apnea Syndrome, 2014

8 33% increase in PSQI score in 145 men (6 months). The Pittsburgh Sleep Quality Index: A New Instrument for Psychiatric Practice and Research, Buysse 1998; Validation of the Pittsburgh Sleep Quality Index (PSQI) and the Epworth Sleepiness Scale in Older Black and White Women Beaudreau, 2012

9 Dutch Apnea Society (Apneuvereniging) survey based on 75 NightBalance users for an average of 2.2 years; 2017

10 Sex influences endothelial function in sleep-disordered breathing. Faulx MD1, Larkin EK, Hoit BD, Aylor JE, Wright AT, Redline S. Sleep. 2004 Sep 15;27(6):1113-20.

11 Cardiovascular mortality in women with obstructive sleep apnea with or without continuous positive airway pressure treatment: a cohort study. Campos-Rodriguez F1, Martinez-Garcia MA, de la Cruz-Moron I, Almeida-Gonzalez C, Catalan-Serra P, Montserrat JM. Ann Intern Med. 2012 Jan 17;156(2):115-22.

Berry, R. et al, NightBalance Sleep Position Trainer Device Versus Auto-Adjusting Positive Airway Pressure for treatment of Positional Obstructive Sleep Apnea, Journal of Clinical Sleep Medicine, 2019, Vol. 5, No.7, 947-956

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