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The American Thoracic Society Sleep Core Curriculum updates clinicians on important sleep topics, presented during the annual meeting, and appearing in summary here. This year's sleep core theme is sleep-disordered breathing and its management. Topics range from pathophysiological mechanisms for the association of obstructive sleep apnea (OSA) and metabolic syndrome, surgical modalities of OSA treatment, comorbid insomnia and OSA, central sleep apnea, and sleep practices during a pandemic. OSA has been associated with metabolic syndrome, independent of the role of obesity, and the pathophysiology suggests a role for sleep fragmentation and intermittent hypoxia in observed metabolic outcomes. In specific patient populations, surgical treatment modalities for OSA have demonstrated large reductions in objective disease severity compared with no treatment and may facilitate adherence to positive airway pressure treatment. Patient-centered approaches to comorbid insomnia and sleep apnea include evaluating for both OSA and insomnia simultaneously and using shared-decision making to determine the order and timing of positive airway pressure therapy and cognitive behavioral therapy for insomnia. The pathophysiology of central sleep apnea is complex and may be due to the loss of drive to breathe or instability in the regulatory pathways that control ventilation. Pandemic-era sleep practices have evolved rapidly to balance safety and sustainability of care for patients with sleep-disordered breathing.

Objective: To develop an expert consensus statement regarding persistent pediatric obstructive sleep apnea (OSA) focused on quality improvement and clarification of controversies. Persistent OSA was defined as OSA after adenotonsillectomy or OSA after tonsillectomy when adenoids are not enlarged. Methods: An expert panel of clinicians, nominated by stakeholder organizations, used the published consensus statement methodology from the American Academy of Otolaryngology‐Head and Neck Surgery to develop statements for a target population of children aged 2‐18 years. A medical librarian systematically searched the literature used as a basis for the clinical statements. A modified Delphi method was used to distill expert opinion and compose statements that met a standardized definition of consensus. Duplicate statements were combined prior to the final Delphi survey. Results: After 3 iterative Delphi surveys, 34 statements met the criteria for consensus, while 18 statements did not. The clinical statements were grouped into 7 categories: general, patient assessment, management of patients with obesity, medical management, drug‐induced sleep endoscopy, surgical management, and postoperative care. Conclusion: The panel reached a consensus for 34 statements related to the assessment, management and postoperative care of children with persistent OSA. These statements can be used to establish care algorithms, improve clinical care, and identify areas that would benefit from future research. [ABSTRACT FROM AUTHOR]

Candidacy evaluation for hypoglossal nerve stimulation (HGNS) is resource intensive. This proof-of-concept study investigates use of in-office volitional snore during flexible laryngoscopy as an efficient, cost-effective screening tool for HGNS evaluation. Adults with moderate to severe obstructive sleep apnea that failed continuous positive airway pressure treatment (n = 41) underwent evaluation for HGNS from 2018 to 2019. Volitional snore and drug-induced sleep endoscopy (DISE) data were collected and scored by VOTE classification (velum/palate, oropharynx, tongue base, epiglottis). A chi-square test of independence was performed that demonstrated a significant relationship between volitional snore and DISE (χ2 = 4.39, P =.036) for velum collapse pattern. Sensitivity and specificity of volitional snore for detecting velum collapse pattern were 93.6% (95% CI, 75.6%-99.2%) and 40% (95% CI, 12.2%-73.8%), respectively, illustrating its utility in screening for HGNS. Patients who demonstrate anterior-posterior velum collapse on volitional snore may be excellent candidates for confirmatory DISE at the time of HGNS implantation. [ABSTRACT FROM AUTHOR]

Objective: Uvulopalatopharyngoplasty (UPPP) is the most common surgical procedure performed to treat obstructive sleep apnea (OSA). This surgery, when performed alone, benefits only a minority of patients. This study was undertaken to determine the efficacy of oral appliance (OA) therapy following unsuccessful UPPP and assess for specific patient and polysomnographic characteristics that may identify those patients most likely to benefit from this combined treatment strategy. Study Design: Retrospective of clinical outcomes in patients undergoing UPPP followed by treatment with an OA. Methods: Polysomnographic results (baseline, status post‐UPPP, and status post‐UPPP with oral appliance use), age, gender, race, and body mass index were subjected to statistical analysis. Results: The mean apnea hypopnea index (AHI) decreased from 23.6 at baseline to 8.6 following UPPP and oral appliance therapy. The mean O2 nadir increased from 83% at baseline to 89.9% following UPPP and treatment with an oral appliance. Fifty percent of patients (9/18) achieved an AHI <5 and were deemed "cured" of their disease. Seventy‐three percent of patients (13/18) achieved benefit with an AHI <20 and ≥50% reduction in their baseline AHI, deemed "successful therapy." No statistically relevant demographic or polysomnographic differences were found between those who were "cured" and those with persistent disease with the exception that the O2 nadir status post UPPP was found to be lower in the "cured" group. Conclusion: Oral appliance therapy is an effective treatment option for the majority of patients who have persistent obstructive sleep apnea following unsuccessful UPPP. Level of Evidence: 4 [ABSTRACT FROM AUTHOR]

Objective Evaluate the correlation between Friedman Tongue Position (FTP) and airway cephalometrics in patients with obstructive sleep apnea (OSA). Study Design Retrospective review of adult patients with OSA undergoing Cone Beam Computed Tomography (CBCT). Methods Collected data included age, sex, body mass index, apnea hypopnea index, FTP, and airway cephalometric parameters. Data analyses were performed using ANOVA, dichotomous t-testing, and linear regression. Results 203 patients were included in the analysis. (M:F 132:71). The mean posterior airway space (PAS) was inversely correlated ( p = 0.001, r =.119) with higher FTP grades with means of 12.3 mm, 7.9 mm, 6.6 mm, and 4.3 mm, I-IV respectively. Minimal cross-sectional area for patients with FTP I-IV was 245.7, 179.8, 137.6, and 74.2 mm, 2 respectively ( p = 0.002, r = .095). Mean hyoid-mandibular plane (H-MP) for FTP I-IV was 20.6 mm, 20.4 mm, 24.7 mm, and 28.9 mm respectively. No statistically significant difference between H-MP values when comparing patients with FTP I or II ( p = 0.22). There were statistically significant differences when these two groups were individually compared to FTP III and IV ( p = 0.002). Linear regression analysis confirmed an independent association between FTP and PAS (β = −2.06, p < 0.001), minimal cross-sectional area (β = −45.07, p = 0.02), and H-MP (β = 3.03, p = 0.01) controlling for BMI, age, AHI, and sex. Conclusions Use of FTP is supported by objective CBCT cephalometric results, in particular the PAS, minimal cross-sectional area, and H-MP. Understanding the correlation between objective measurements of retroglossal collapse should allow Otolaryngologists to more confidently select patients who may require surgery to address the retroglossal area, particularly when the ability to perform cephalometric analysis is not possible Level of Evidence 4. [ABSTRACT FROM AUTHOR]

Objectives/Hypothesis Most patients with obstructive sleep apnea (OSA) have multilevel obstruction. Improved outcomes with multilevel surgery compared to isolated palatal surgery have been well documented. Despite this, surgical practice patterns in the United States have been slow to change. The purpose of this study was to evaluate whether current practice patterns are a reflection of limited surgical residency training in hypopharyngeal procedures. Study Design Cross-sectional Internet survey. Methods Program directors from 103 accredited U.S. otolaryngology residency programs were surveyed regarding past (2000, 2005) and more recent (2010) resident surgical competency in operative techniques for treatment of OSA. Results Of the 48 survey respondents, 85%, 90%, and 100% reported resident surgical competency for oropharyngeal procedures in 2000, 2005, and 2010, respectively. Uvulopalatopharyngoplasty and tonsillectomy were the most common procedures reported in all 3 years. In contrast, 63%, 71%, and 83% reported resident surgical competency for hypopharyngeal procedures in 2000, 2005, and 2010. Lingual tonsillectomy was the most common procedure in all 3 years. Conclusion Surgical practice patterns in the United States do not reflect current practice recommendations for treatment of OSA, which emphasize multilevel surgery. Limited surgical residency training in hypopharyngeal procedures may be a contributing factor, although there appears to be an increasing trend in resident competency. Improvement in the scope of resident surgical training for treatment of OSA may lead to improved surgical outcomes. Level of Evidence 3b. Laryngoscope, 124:579-582, 2014 [ABSTRACT FROM AUTHOR]