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Electrical stimulation as a therapeutic approach in obstructive sleep apnea — a meta-analysis

  • Sleep Breathing Physiology and Disorders • Original Article
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Abstract

Purpose

Electrical stimulation of the upper airway dilator muscles is an emerging treatment for obstructive sleep apnea (OSA). Invasive hypoglossal nerve stimulation (HNS) has been accepted as treatment alternative to continuous positive airway pressure (CPAP) for selected patients, while transcutaneous electrical stimulation (TES) of the upper airway is being investigated as non-invasive alternative.

Methods

A meta-analysis (CRD42017074674) on the effects of both HNS and TES on the apnea-hypopnea index (AHI) and the Epworth Sleepiness Scale (ESS) in OSA was conducted including published evidence up to May 2018. Random-effects models were used. Heterogeneity and between-study variance were assessed by I2 and τ2, respectively.

Results

Of 41 identified clinical trials, 20 interventional trials (n = 895) could be pooled in a meta-analysis (15 HNS [n = 808], 5 TES [n = 87]). Middle-aged (mean ± SD 56.9 ± 5.5 years) and overweight (body mass index 29.1 ± 1.5 kg/m2) patients with severe OSA (AHI 37.5 ± 7.0/h) were followed-up for 6.9 ± 4.0 months (HNS) and 0.2 ± 0.4 months (TES), respectively. The AHI improved by − 24.9 h−1 [95%CI − 28.5, − 21.2] in HNS (χ2 79%, I2 82%) and by − 16.5 h−1 [95%CI − 25.1, − 7.8] in TES (χ2 7%, I2 43%; both p < 0.001). The ESS was reduced by − 5.0 (95%CI − 5.9, − 4.1) (p < 0.001).

Conclusion

Both invasive and transcutaneous electrical stimulation reduce OSA severity by a clinically relevant margin. HNS results in a clinically relevant improvement of symptoms. While HNS represents an invasive treatment for selected patients with moderate to severe OSA, TES should be further investigated as potential non-invasive approach for OSA.

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Funding

Swiss Lung Foundation (EIS). European Respiratory Society (LTRF 201801-00285, EIS). Professor Steier’s contributions were partially supported by the National Institute for Health Research (NIHR) Biomedical Research Centre based at Guy’s and St Thomas’ NHS Foundation trust and King’s College London, UK. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health.

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Authors and Affiliations

  1. Lane Fox Respiratory Unit and Sleep Disorders Centre, Guy’s and St Thomas’ Hospital NHS Foundation Trust, London, SE1 7EH, UK

    Deeban Ratneswaran, Miral Al-Sherif, Baiting He, Michael CF Cheng, Joerg Steier & Esther I Schwarz

  2. Faculty of Life Sciences and Medicine, King’s College, London, UK

    Ahmad Guni, Miral Al-Sherif & Joerg Steier

  3. Department of Cardiovascular, Sleep Disorder Centre, Neural and Metabolic Sciences, IRCCS Istituto Auxologico Italiano, Milan, Italy

    Martino F Pengo

  4. Department of Pulmonology and Sleep Disorders Centre, University Hospital of Zurich, 8091, Zurich, Switzerland

    Esther I Schwarz

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  1. Deeban Ratneswaran
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  2. Ahmad Guni
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Contributions

Conception and design: E.I.S., J.S., M.F.P. Protocol writing: J.S, E.I.S., M.F.P. Literature search: C.R., A.G, E.I.S. Data extraction: E.I.S., A.G., C.R. Statistical analysis: E.I.S. Interpretation of the findings: all authors. Manuscript drafting: C.R, E.I.S., J.S. All authors critically revised and approved the final version to be published.

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Correspondence to Deeban Ratneswaran or Esther I Schwarz.

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Competing interests

J.S. is named inventor on a patent for an apparatus to use transcutaneous electrical stimulation to treat obstructive sleep apnea and snoring (WO2016124739A1). No other conflicts of interest related to the content of the manuscript are reported.

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The systematic review has been registered on PROSPERO (PROSPERO 2017:CRD42017074674).

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Dr. Esther I Schwarz is the guarantor of this work and, as such, had full access to all the data in the study and takes responsibility for the integrity of the data, the accuracy of the data analysis, and the integrity of the submission as a whole.

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The sponsors had no role in the design or conduct of the study, analysis and interpretation of the data, or writing the manuscript.

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Ratneswaran, D., Guni, A., Pengo, M.F. et al. Electrical stimulation as a therapeutic approach in obstructive sleep apnea — a meta-analysis. Sleep Breath 25, 207–218 (2021). https://doi.org/10.1007/s11325-020-02069-2

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