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Effect of prone positioning in mild to moderate obstructive sleep apnea syndrome

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Abstract

Background

Sleeping in prone position could be effective in the management of obstructive sleep apnea (OSA) syndrome by reducing the gravity effect on the upper airway and hence collapsibility. Effect of pure prone positioning (PPP) treatment was investigated in mild to moderate OSA.

Patients and methods

Twenty-nine mild to moderate OSA patients (17 males, 12 females) who gave informed consent were tested with polysomnography at diagnostic and PPP nights. PPP device consisted of a pillow mounted on a table with a hole in the middle keeping the neck 180° extended in prone position. Mean ± SD of age and AHI were 48.4 ± 10.6 and 15.5 ± 6.2, respectively. Patients did not have abdominal and/or truncalobesity, or any condition that could interfere with prone sleeping.

Results

AHI (mean difference: PPP treatment − diagnostic night: −5.2/h, 95 % confidence interval [CI]: −0.1/h to −10.3/h, p = 0.04) and sleep oxygen saturation below 90 % (mean difference: −1.80 %, 95 % CI: −0.22 % to −3.37 %, p = 0.02) and sleep efficiency (81.0 ± 21.2 % and 88.1 ± 7.1 %, respectively, p = 0.02) were significantly lower in PPP than diagnostic night. Response to PPP treatment defined as AHI <5/h in the PPP night was observed in 15 (51.7 %) patients, with a better rate in female than male patients (9/12 vs. 6/17, respectively, p = 0.03).

Conclusions

To our knowledge, this is the first study to examine the effect of prone positioning in the treatment of mild to moderate OSA. Application of PPP with a more comfortable design in a randomized clinical trial is required to investigate its long term effect in the treatment of mild to moderate OSA.

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Abbreviations

AHI:

Apnea–hypopnea index

AI:

Apnea index

BMI:

Body mass index

CPAP:

Continuous positive airway pressure

ECG:

Electrocardiography

EEG:

Electroencephalography

EMG:

Electromyography

EOG:

Elecrooculography

ESS:

Epworth Sleepiness Scale

HI:

Hypopnea index

ICSD-2:

International Classification of Sleep Disorders 2

MRI:

Magnetic resonance imaging

NREM 1–2 %:

Percentage of non rapid eye movement stage 1 and stage 2 sleep

NREM 3 %:

Percentage of slow wave sleep

NREM:

Non-rapid eye movement

OSA:

Obstructive sleep apnea

PPP:

Pure prone positioning

PSG:

Polysomnography

REM:

Rapid eye movement

SaO2 :

Arterial oxygen saturation

T90%:

Percentage of sleep spent below 90 % SaO2

TST:

Total sleep time

References

  1. Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S (1993) The occurrence of sleep-disordered breathing among middle-aged adults. N Engl J Med 328:1230–1235

    Article  CAS  PubMed  Google Scholar 

  2. Kakkar RK, Berry RB (2007) Positive airway pressure treatment for obstructive sleep apnea. Chest 132:1057–1072

    Article  PubMed  Google Scholar 

  3. Polo O, Berthon-Jones M, Douglas NJ, Sullivan CE (1994) Management of obstructive sleep apnoea/hypopnoea syndrome. Lancet 344:656–660

    Article  CAS  PubMed  Google Scholar 

  4. McArdle N, Devereux G, Heidarnejad H, Engleman HM, Mackay TW, Douglas NJ (1999) Long-term use of CPAP therapy for sleep apnea/hypopnea syndrome. Am J Respir Crit Care Med 159:1108–1114

    Article  CAS  PubMed  Google Scholar 

  5. Engleman HM, Wild MR (2003) Improving CPAP use by patients with the sleep apnoea/hypopnoea syndrome (SAHS). Sleep Med Rev 7:81–99

    Article  PubMed  Google Scholar 

  6. Cartwright RD (1984) Effect of sleep position on sleep apnea severity. Sleep 7:110–114

    CAS  PubMed  Google Scholar 

  7. Oksenberg A, Silverberg DS, Arons E, Radwan H (1997) Positional vs nonpositional obstructive sleep apnea patients: anthropomorphic, nocturnal polysomnographic, and multiple sleep latency test data. Chest 112:629–639

    Article  CAS  PubMed  Google Scholar 

  8. Cartwright RD, Lloyd S, Lilie J, Kravitz H (1985) Sleep position training as treatment for sleep apnea syndrome: a preliminary study. Sleep 8:87–94

    CAS  PubMed  Google Scholar 

  9. Jokic R, Klimaszewski A, Crossley M, Sridhar G, Fitzpatrick MF (1999) Positional treatment vs continuous positive airway pressure in patients with positional obstructive sleep apnea syndrome. Chest 115:771–781

    Article  CAS  PubMed  Google Scholar 

  10. Mador MJ, Kufel TJ, Magalang UJ, Rajesh SK, Watwe V, Grant BJ (2005) Prevalence of positional sleep apnea in patients undergoing polysomnography. Chest 128:2130–2137

    Article  PubMed  Google Scholar 

  11. Bignold JJ, Deans-Costi G, Goldsworthy MR, Robertson CA, McEvoy D, Catcheside PG, Mercer JD (2009) Poor long-term patient compliance with the tennis ball technique for treating positional obstructive sleep apnea. J Clin Sleep Med 5:428–430

    PubMed Central  PubMed  Google Scholar 

  12. Heinzer RC, Pellaton C, Rey V, Rossetti AO, Lecciso G, Haba-Rubio J, Tafti M, Lavigne G (2012) Positional therapy for obstructive sleep apnea: an objective measurement of patients2 usage and efficacy at home. Sleep Med 13:425–428

    Article  PubMed  Google Scholar 

  13. Matsuzawa Y, Hayashi S, Yamaguchi S, Yoshikawa S, Okada K, Fujimoto K, Sekiguchi M (1995) Effect of prone position on apnea severity in obstructive sleep apnea. Intern Med 34:1190–1193

    Article  CAS  PubMed  Google Scholar 

  14. Iber C, Ancoli-Israel S, Chesson AL, Quan SF (2007) The AASM manual for the scoring of sleep and associated events: rules, terminology, and technical specifications. Westchester

  15. International Classification of Sleep Sisorders: Diagnostic and coding manual (2005) 2nd edn. Westchester

  16. The Report of an American Academy of Sleep Medicine Task Force (1999) Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research. Sleep 22:667–689

    Google Scholar 

  17. Jovic R, Klimaszewski A, Crossley M, Sridhar G, Fitzpatrick MF (1999) Positional treament vs. continous positive airway pressure in patients with positional obstructive sleep apnea syndrome. Chest 115:771–781

    Article  Google Scholar 

  18. Driver HS, Saberi F, Chatha N, Urton AM, Munt P, Fitzpatrick MF (2007) How reliable is the diagnosis of positional obstructive sleep apnea? Sleep Diagn Ther 2:31–34

    Google Scholar 

  19. O'Connor C, Thornley KS, Hanly PJ (2000) Gender differences in the polysomnographic features of obstructive sleep apnea. Am J Respir Crit Care Med 161:1465–1472

    Article  PubMed  Google Scholar 

  20. Weiner EA, Girish M, Harris C, Shepard JW (2001) Effectiveness of the prone position in the treatment of obstructive sleep apnea. Sleep 24:A267–268

    Google Scholar 

  21. George CF, Millar TW, Kryger MH (1988) Sleep apnea and body position during sleep. Sleep 11:90–99

    CAS  PubMed  Google Scholar 

  22. Eckert DJ, Malhotra A (2008) Pathophysiology of adult obstructive sleep apnea. Proc Am Thorac Soc 5:144–153

    Article  PubMed Central  PubMed  Google Scholar 

  23. Martin SE, Mathur R, Marshall I, Douglas NJ (1997) The effect of age, sex, obesity and posture on upper airway size. Eur Respir J 10:2087–2090

    Article  CAS  PubMed  Google Scholar 

  24. Popovic RM, White DP (1995) Influence of gender on waking genioglossal electromyogram and upper airway resistance. Am J Respir Crit Care Med 152:725–731

    Article  CAS  PubMed  Google Scholar 

  25. Leech JA, Onal E, Dulberg C, Lopata MA (1988) A comparison of men and women with occlusive sleep apnea syndrome. Chest 94:983–988

    Article  CAS  PubMed  Google Scholar 

  26. Oliven A, Aspandiarov E, Gankin I, Gaitini L, Tov N (2008) Collapsibility of the relaxed pharynx and risk of sleep apnoea. Eur Respir J 32:1309–1315

    Article  CAS  PubMed  Google Scholar 

  27. Neill AM, Angus SM, Sajkov D, McEvoy RD (1997) Effects of sleep posture on upper airway stability in patients with obstructive sleep apnea. Am J Respir Crit Care Med 155:199–204

    Article  CAS  PubMed  Google Scholar 

  28. Walsh JH, Leigh MS, Paduch A, Maddison KJ, Armstrong JJ, Sampson DD, Hillman DR, Eastwood PR (2008) Effect of body posture on pharyngeal shape and size in adults with and without obstructive sleep apnea. Sleep 31:1543–9

    PubMed Central  PubMed  Google Scholar 

  29. Oksenberg A, Khamaysi I, Silverberg DS, Tarasiuk A (2000) Association of body position with severity of apneic events in patients with severe nonpositional obstructive sleep apnea. Chest 118:1018–24

    Article  CAS  PubMed  Google Scholar 

  30. Takasaki Y, Kamio K, Okamoto M, Ohta Y, Yamabayashi H (1993) Changes in diaphragmatic EMG activity during sleep in space. Am Rev Respir Dis 148:612–617

    Article  CAS  PubMed  Google Scholar 

  31. Ishikawa T, Isono S, Aiba J, Tanaka A, Nishino T (2002) Prone position increases collapsibility of the passive pharynx in infants and small children. Am J Respir Crit Care Med 166:760–764

    Article  PubMed  Google Scholar 

  32. Lijowska AS, Reed NW, Chiodini BA, Thach BT (1997) Sequential arousal and airway-defensive behavior of infants in asphyxial sleep environments. J Appl Physiol 83:219–228

    CAS  PubMed  Google Scholar 

  33. Pereira KD, Rathi NK, Fatakia A, Haque SA, Castriotta RJ (2008) Body position and obstructive sleep apnea in 8–12-month-old infants. Int J Pediatr Otorhinolaryngol 72(6):897–900

    Article  PubMed  Google Scholar 

  34. Raoof S, Goulet K, Esan A, Hess DR, Sessler CN (2010) Severe hypoxemic respiratory failure: Part 2. Nonventilatory strategies. Chest 137:1437–1448

    Article  PubMed  Google Scholar 

  35. Pelosi P, Brazzi L, Gattinoni L (2002) Prone position in acute respiratory distress syndrome. Eur Respir J 20:1017–1028

    Article  CAS  PubMed  Google Scholar 

  36. Toussaint M, Luthringer R, Schaltenbrand N, Carelli G, Lainey E, Jacqmin A, Muzet A, Macher JP (1995) First-night effect in normal subjects and psychiatric inpatients. Sleep 18:463–469

    CAS  PubMed  Google Scholar 

  37. Koenig JS, Thach BT (1988) Effects of mass loading on the upper airway. J Appl Physiol 64:2294–2299

    CAS  PubMed  Google Scholar 

  38. Randerath WJ, Verbraecken J, Andreas S, Bettega G, Boudewyns A, Hamans E, Jalbert F, Paoli R, Sanner B, Smith I, Stuck BA, Lacassagne L, Marklund M, Maurer JT, Pepin JL, Valipour A, Verse T, Fietze I (2011) European Respiratory Society task force on non-CPAP therapies in sleep apnoea. Non-CPAP therapies in obstructive sleep apnoea. Eur Respir J 37:1000–1028

    Article  CAS  PubMed  Google Scholar 

  39. Permut I, Diaz-Abad M, Chatila W, Crocetti J, Gaughan JP, D’Alonzo GE, Krachman SL (2010) Comparison of positional therapy to CPAP in patients with positional obstructive sleep apnea. J Clin Sleep Med 6:238–243

    PubMed Central  PubMed  Google Scholar 

  40. Bignold JJ, Mercer JD, Antic NA, McEvoy RD, Catcheside PG (2011) Accurate position monitoring and improved supinedependent obstructive sleep apnea with a new position recording and supine avoidance device. J Clin Sleep Med 7:376–383

    PubMed Central  PubMed  Google Scholar 

  41. Choi JH, Park TY, Hong JH, Kim SJ, Park DS, Miyazaki S, Lee SH, Shin C, Lee J (2009) Efficacy study of a vest-type device for positional therapy in position dependent snorers. Sleep Biol Rythms 7:181–187

    Article  Google Scholar 

  42. Zuberi NA, Rekab K, Nguyen HV (2004) Sleep apnea avoidance pillow effects on obstructive sleep apnea syndrome and snoring. Sleep Breath 8:201–207

    Article  PubMed  Google Scholar 

  43. Wenzel S, Smith E, Leiacker R, Fischer Y (2007) Efficacy and long-term compliance of the vest preventing the supine position in patients with obstructive sleep apnea. Laryngo-Rhino-Otologie 86:579–583

    Article  CAS  PubMed  Google Scholar 

  44. Loord H, Hultcrantz E (2007) Positioner—a method for preventing sleep apnea. Acta Otolaryngol 127:861–868

    Article  PubMed  Google Scholar 

  45. Skinner MA, Kingshott RN, Filsell S, Taylor R (2009) Efficacy ofthe ‘tennis ball technique’ versus nCPAP in the management ofposition-dependent obstructive sleep apnoea syndrome. Respirology 13:708–715

    Article  Google Scholar 

  46. Svatikova A, Chervin RD, Wing JJ, Sanchez BN, Migda EM, Brown DL (2011) Positional therapy in ischemic stroke patientswith obstructive sleep apnea. Sleep Med 12:262–266

    Article  PubMed  Google Scholar 

  47. Van Maanen JP, Richard W, van Kesteren ER, Ravesloot MJL, Laman DM, Hilgevoord AAJ, de Vries N (2011) Evaluation of a new simple treatment for positional sleep apnea patients. J Sleep Res. doi:10.1111/j.1365-2869.2011.00974.x

    PubMed  Google Scholar 

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Acknowledgments

The authors thank Dr. Timothy I. Morgenthaler (Department of Pulmonary Diseases, Critical Care and Sleep Medicine, Mayo Clinic, Rochester, MN, USA) for revising the manuscript and for his helpful comments on the manuscript. The authors also thank Dr. Ahmet Ugur Demir (Department of Pulmonary Diseases, Medical Faculty of Hacettepe University, Ankara, Turkey) for statistical assistance and helpful comments on the manuscript. The authors are grateful to Dr. Vahit Özener (Department of Radiology, Baris Medical Imaging Center, Izmir, Turkey) for radiologic imaging and evaluation of the MRI images of the upper airway.

Author contribution

Arman Afrashi’s contributions were study design, data collection, writing and revising the manuscript. Zeynep Zeren Ucar’s contributions were study data collection, design, statistical analysis, creation of the figures and tables, and writing and revising the manuscript.

Conflict of interest

The authors declare no financial support. Abstract of this study was presented in the CHEST 2011 Annual Meeting in Honolulu, HI.

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Authors and Affiliations

  1. Department of Otolaryngology — Head and Neck Surgery, Izmir Dr. Suat Seren Chest Diseases and Surgery Training and Research Hospital, Izmir, Turkey

    Arman Afrashi

  2. Department of Sleep Disorders, Izmir Dr. Suat Seren Chest Diseases and Surgery Training and Research Hospital, 35110, Izmir, Turkey

    Zeynep Zeren Ucar

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  1. Arman Afrashi
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Correspondence to Zeynep Zeren Ucar.

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Afrashi, A., Ucar, Z.Z. Effect of prone positioning in mild to moderate obstructive sleep apnea syndrome. Sleep Breath 19, 1027–1034 (2015). https://doi.org/10.1007/s11325-014-0985-x

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