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Stellenwert der Nicht-nCPAP-Verfahren in der Therapie des obstruktiven Schlafapnoe-Syndroms

Relevance of non-CPAP treatment options in the therapy of the obstructive sleep apnoea syndrome

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Zusammenfassung

Ein Großteil der Patienten mit einem obstruktiven Schlafapnoe-Syndrom (OSAS) sucht nach konservativen oder operativen Behandlungsverfahren mit deren Hilfe sie die kontinuierliche Positivdruckatmung (CPAP) vermeiden können. Angesichts der hohen Prävalenz der Erkrankung und der Beeinträchtigung der Patienten wird eine Vielzahl von Methoden angeboten, mit denen eine definitive Heilung oder entscheidende Besserung der Erkrankung versprochen wird. Demgegenüber können nur selten fundierte Daten angegeben werden, die eine evidenzbasierte Bewertung der Verfahren ermöglicht. Ziel dieser Arbeit war es daher, den wissenschaftlichen Kenntnisstand zu den Nicht-CPAP-Verfahren zu erfassen und dem Schlafmediziner Empfehlungen zur Beratung und Behandlung der Patienten zu geben. Die Datenlage stellete sich für die meisten Nicht-nCPAP-Verfahren als sehr unbefriedigend dar. Ausreichende Untersuchungen liegen lediglich für die Unterkieferprotrusionsschienen, die beim leichten bis allenfalls mittelgradigen OSAS eine signifikante Besserung der Atmung bewirken können, und die maxillo-mandibuläre Osteotomie, die auch im Langzeitverlauf ausreichend effizient ist, jedoch nur Einzelfällen angewandt wird, vor. Gewichtsreduktion oder Lagetherapie können nicht als alleinige, allenfalls als ergänzende Therapie des OSAS empfohlen werden. Muskelresezierende Verfahren am Weichgaumen sind abzulehnen. Aber auch die Effekte muskelschonender Operationsverfahren am Weichgaumen sind individuell kaum vorhersehbar und lassen über die Jahre oft nach. Die Ergebnisse nach Operationen an and eren anatomischen Regionen scheinen dagegen stabil zu bleiben. Kombinierte Eingriffe im Sinne einer Multi-Level-Chirurgie gewinnen sekundär nach erfolgloser oder abgebrochener Beatmungsbehandlung an Bedeutung, auch wenn hier noch weitere Daten nötig sind. Alle übrigen Verfahren entbehren der ausreichenden Validierung oder sind beim Schlafapnoe-Syndrom als nicht indiziert anzusehen.

Summary

Many patients with the obstructive sleep apnoea syndrome (OSAS) look for alternative conservative or surgical therapies to avoid treatment with continuous positive airway pressure. In view of the high prevalence and the relevant impairment of the patients, lots of methods are offered that promise a definitive cure or relevant improvement of OSAS. The “Apnoea” working group of the German Society of Sleep Medicine and Research established a task force to evaluate the scientific literature on non-CPAP therapies in the treatment of OSAS according to the standards of evidence-based medicine (EBM). This paper presents the results of the task force. The authors performed a literature search until 21 December 2005 (Medline and hand search of relevant papers). The studies were evaluated according the recommendations of the “Oxford Centre for Evidence-based Medicine Levels of Evidence”. The data were unsatisfactory for most of the methods. Sufficient data were available for intraoral appliances (IOA) and maxillomandibular osteotomy (MMO). IOAs can reduce mild to moderate respiratory disturbances; MMOs are efficient in the short- and long-term but are performed only in special situations such as craniofacial dysmorphias. Weight reduction and body positioning cannot be recommended as a single treatment of OSAS. Most surgical procedures still lack sufficient data according to EBM criteria. Resections of muscular tissue within the soft palate have to be strictly avoided. But even success following gentle soft palate procedures is difficult to predict and often decreases over the years. Results in other anatomical regions seem to be more stable over time. Today combined surgeries in the sense of multilevel surgery concepts are of increasing interest in the secondary treatment after failure of nasal ventilation therapy, although more data from prospective controlled studies are needed. There is no evidence for any other treatment options studied in this paper.

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Authors and Affiliations

  1. Klinik für Pneumologie und Allergologie, Zentrum für Schlaf- und Beatmungsmedizin, Institut für Pneumologie an der Universität Witten/Herdecke, Krankenhaus Bethanien, Aufderhöherstraße 169-175, D-42699, Solingen

    Winfried Randerath & Wolfgang Galetke

  2. Asklepios Fachkliniken, München-Gauting

    Maximilian Bauer

  3. Klinik m. S. Kardiologie, Angiologie, Pulmologie, Charité—Universitätsmedizin, Berlin

    Alexander Blau & Ingo Fietze

  4. Schlafinedizinisches Zentrum, Krank enhaus Großhansdorf, Mannheim, Deutschland

    Holger Hein

  5. Schlafinedizinisches Zentrum, Universitäts-HNO-Klinik Mannheim, Mannheim, Deutschland

    Joachim T. Maurer & Boris A. Stuck

  6. Bergman annsheil, Bochum

    Maritta Orth

  7. Kliniken St. Antonius, Zentrum für Innere Medizin (ZIM), Schwerpunkt Pneumologie/Allergologie, Schlaf-und Beamtungsmedizin, Wuppertal

    Kurt Rasche

  8. Klinik Ambrock, Klinik für Pneumologie, Allergologie und Schlafimedizin, Hagen

    Karl-Heinz Rühle

  9. Medizinische Klinik, Bethesda Krankenhaus, Wuppertal

    Bernd Sanner

  10. Klinik und Poliklinik für HNO-K rankheiten, Universitätsklinikum des Saarlandes, Niederland

    Thomas Verse

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  1. Winfried Randerath
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  2. Maximilian Bauer
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  12. Boris A. Stuck
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  13. Thomas Verse
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Task Force der Arbeitsgruppe Apnoe der DGSM

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Correspondence to Winfried Randerath.

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Randerath, W., Bauer, M., Blau, A. et al. Stellenwert der Nicht-nCPAP-Verfahren in der Therapie des obstruktiven Schlafapnoe-Syndroms. Somnologie 10, 67–98 (2006). https://doi.org/10.1007/j.1439-054X.2006.00082.x

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