Sleep and Breathing

, Volume 23, Issue 1, pp 153–160 | Cite as

Hypoglossal nerve stimulation therapy on peripheral arterial tonometry in obstructive sleep apnea: a pilot study

  • Allison K. Ikeda
  • Qiao Li
  • Arshed A. Quyuumi
  • Raj C. DedhiaEmail author
Sleep Breathing Physiology and Disorders • Original Article



Hypoglossal nerve stimulation (HGNS) is being increasingly utilized in the setting of moderate-severe obstructive sleep apnea (OSA). While moderate-severe OSA confers excess cardiovascular risk, the impact of HGNS on cardiovascular requires further investigation. With the advent of peripheral arterial tonometry (PAT), one can non-invasively study real-time changes to the autonomic nervous system. This study evaluates the effect of HGNS therapy on autonomic output, using PAT-integrated polysomnography.


Subjects included adult patients undergoing 2-month post-operative HGNS titration studies with PAT-integrated polysomnography. Apneic and hypopneic events with arousal during stage 2 sleep were identified at increasing levels of stimulation. With each event, PAT signal attenuations were recorded, processed, and analyzed.


Nine subjects were enrolled, and eight met inclusion criteria (mean age 67.8 ± 12.4 years; 50% female). The PAT signal did not significantly change before and during stimulation (mean pre-stimulation 43.4 ± 1.7, mean intra-stimulation 41.1 ± 22.5, p = 0.53) in any patient. The ratio of the PAT signal maximum and minimum amplitudes during sleep breathing events largely demonstrated very weak correlation (R2 = <0.12). Across all subjects, poor linear correlation was present between HGNS and PAT signal attenuation (R2 = 0.028) in both adjusted and unadjusted analyses.


Using PAT-integrated polysomnography, PAT output does not appear to be affected by HGNS stimulation at clinical thresholds. These findings support the absence of autonomic system alterations by twelfth nerve stimulation and support the clinical use of PAT-based devices for post-HGNS monitoring. Larger studies examining hard cardiovascular endpoints with HGNS are needed.


Hypoglossal nerve stimulation Peripheral arterial tonometry Obstructive sleep apnea Sympathetic activity Polysomnography 



Everett G. Seay, RPSGT, assisted with adjudication of events and study coordination.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee (place name of institute/committee) and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed consent

Informed consent was obtained from all individual participants included in the study.


  1. 1.
    Young T, Evans L, Finn L, Palta M (1997) Estimation of the clinically diagnosed proportion of sleep apnea syndrome in middle-aged men and women. Sleep 20(9):705–706CrossRefGoogle Scholar
  2. 2.
    Young T, Peppard PE, Taheri S (2005) Excess weight and sleep-disordered breathing. J Appl Physiol (1985) 99(4):1592–1599CrossRefGoogle Scholar
  3. 3.
    Newman AB, Foster G, Givelber R, Nieto FJ, Redline S, Young T (2005) Progression and regression of sleep-disordered breathing with changes in weight: the sleep heart health study. Arch Intern Med 165(20):2408–2413CrossRefGoogle Scholar
  4. 4.
    Kapur VK (2010) Obstructive sleep apnea: diagnosis, epidemiology, and economics. Respir Care 55(9):1155–1167Google Scholar
  5. 5.
    Kapur V, Blough DK, Sandblom RE, Hert R, de Maine JB, Sullivan SD, Psaty BM (1999) The medical cost of undiagnosed sleep apnea. Sleep 22(6):749–755CrossRefGoogle Scholar
  6. 6.
    Teran-Santos J, Jimenez-Gomez A, Cordero-Guevara J (1999) The association between sleep apnea and the risk of traffic accidents. Cooperative group Burgos-Santander. N Engl J Med 340(11):847–851CrossRefGoogle Scholar
  7. 7.
    Marin JM et al (2005) Long-term cardiovascular outcomes in men with obstructive sleep apnoea-hypopnoea with or without treatment with continuous positive airway pressure: an observational study. Lancet 365(9464):1046–1053CrossRefGoogle Scholar
  8. 8.
    Punjabi NM, Caffo BS, Goodwin JL, Gottlieb DJ, Newman AB, O’Connor GT, Rapoport DM, Redline S, Resnick HE, Robbins JA, Shahar E, Unruh ML, Samet JM (2009) Sleep-disordered breathing and mortality: a prospective cohort study. PLoS Med 6(8):e1000132CrossRefGoogle Scholar
  9. 9.
    Young T, Finn L, Peppard PE, Szklo-Coxe M, Austin D, Nieto FJ, Stubbs R, Hla KM (2008) Sleep disordered breathing and mortality: eighteen-year follow-up of the Wisconsin sleep cohort. Sleep 31(8):1071–1078Google Scholar
  10. 10.
    Qaseem A, Holty JE, Owens DK, Dallas P, Starkey M, Shekelle P, Clinical Guidelines Committee of the American College of Physicians (2013) Management of obstructive sleep apnea in adults: a clinical practice guideline from the American College of Physicians. Ann Intern Med 159(7):471–483Google Scholar
  11. 11.
    Sawyer AM, Gooneratne NS, Marcus CL, Ofer D, Richards KC, Weaver TE (2011) A systematic review of CPAP adherence across age groups: clinical and empiric insights for developing CPAP adherence interventions. Sleep Med Rev 15(6):343–356CrossRefGoogle Scholar
  12. 12.
    Weaver TE, Grunstein RR (2008) Adherence to continuous positive airway pressure therapy: the challenge to effective treatment. Proc Am Thorac Soc 5(2):173–178CrossRefGoogle Scholar
  13. 13.
    Hamoda MM, Kohzuka Y, Almeida FR (2018) Oral appliances for the management of OSA: an updated review of the literature. Chest 153(2):544–553Google Scholar
  14. 14.
    de Vries GE, Hoekema A, Doff MH, Kerstjens HA, Meijer PM, van der Hoeven J, Wijkstra PJ (2015) Usage of positional therapy in adults with obstructive sleep apnea. J Clin Sleep Med 11(2):131–137Google Scholar
  15. 15.
    Joosten SA, Hamilton GS, Naughton MT (2017) Impact of weight loss management in OSA. Chest 152:194–203CrossRefGoogle Scholar
  16. 16.
    Jacobowitz O (2012) Surgical reconstruction of the upper airway for obstructive sleep apnea. Dent Clin N Am 56(2):453–474CrossRefGoogle Scholar
  17. 17.
    Dedhia RC, Strollo PJ, Soose RJ (2015) Upper airway stimulation for obstructive sleep apnea: past, present, and future. Sleep 38(6):899–906Google Scholar
  18. 18.
    Heiser C, Knopf A, Hofauer B (2017) Surgical anatomy of the hypoglossal nerve: a new classification system for selective upper airway stimulation. Head Neck 39(12):2371–2380CrossRefGoogle Scholar
  19. 19.
    Kent DT, Lee JJ, Strollo PJ Jr, Soose RJ (2016) Upper airway stimulation for OSA: early adherence and outcome results of one center. Otolaryngol Head Neck Surg 155(1):188–193CrossRefGoogle Scholar
  20. 20.
    Heiser C, Knopf A, Bas M, Gahleitner C, Hofauer B (2017) Selective upper airway stimulation for obstructive sleep apnea: a single center clinical experience. Eur Arch Otorhinolaryngol 274(3):1727–1734CrossRefGoogle Scholar
  21. 21.
    Marin JM, Agusti A, Villar I, Forner M, Nieto D, Carrizo SJ, Barbé F, Vicente E, Wei Y, Nieto FJ, Jelic S (2012) Association between treated and untreated obstructive sleep apnea and risk of hypertension. Jama 307(20):2169–2176CrossRefGoogle Scholar
  22. 22.
    Abboud F, Kumar R (2014) Obstructive sleep apnea and insight into mechanisms of sympathetic overactivity. J Clin Invest 124(4):1454–1457CrossRefGoogle Scholar
  23. 23.
    O'Donnell CP, Allan L, Atkinson P, Schwartz AR (2002) The effect of upper airway obstruction and arousal on peripheral arterial tonometry in obstructive sleep apnea. Am J Respir Crit Care Med 166(7):965–971CrossRefGoogle Scholar
  24. 24.
    Bar A, Pillar G, Dvir I, Sheffy J, Schnall RP, Lavie P (2003) Evaluation of a portable device based on peripheral arterial tone for unattended home sleep studies. Chest 123(3):695–703CrossRefGoogle Scholar
  25. 25.
    Zou D, Grote L, Eder DN, Peker Y, Hedner J (2004) Obstructive apneic events induce alpha-receptor mediated digital vasoconstriction. Sleep 27(3):485–489CrossRefGoogle Scholar
  26. 26.
    Penzel T, Fricke R, Becker H, Conradt R, Jerrentrup A, Peter JH (2001) Comparison of peripheral arterial tonometry and invasive blood pressure in obstructive sleep apnea. Sleep 24:A264CrossRefGoogle Scholar
  27. 27.
    Zou D, Grote L, Peker Y, Lindblad U, Hedner J (2006) Validation a portable monitoring device for sleep apnea diagnosis in a population based cohort using synchronized home polysomnography. Sleep 29(3):367–374CrossRefGoogle Scholar
  28. 28.
    Choi JH, Kim EJ, Kim YS, Choi J, Kim TH, Kwon SY, Lee HM, Lee SH, Shin C, Lee SH (2010) Validation study of portable device for the diagnosis of obstructive sleep apnea according to the new AASM scoring criteria: Watch-PAT 100. Acta Otolaryngol 130(7):838–843CrossRefGoogle Scholar
  29. 29.
    Somers VK, Dyken ME, Mark AL, Abboud FM (1993) Sympathetic-nerve activity during sleep in normal subjects. N Engl J Med 328(5):303–307CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  • Allison K. Ikeda
    • 1
  • Qiao Li
    • 2
  • Arshed A. Quyuumi
    • 3
  • Raj C. Dedhia
    • 4
    • 5
    Email author
  1. 1.Emory University School of MedicineAtlantaUSA
  2. 2.Department of Biomedical InformaticsEmory UniversityAtlantaUSA
  3. 3.Division of Cardiology, Department of MedicineEmory University School of MedicineAtlantaUSA
  4. 4.Department of OtolaryngologyEmory University School of MedicineAtlantaUSA
  5. 5.Emory Sleep Center, Emory HealthcareAtlantaUSA

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