Polysomnographic airflow shapes and site of collapse during drug-induced sleep endoscopy.

Background: Differences in the pharyngeal site of collapse influence efficacy of non-continuous positive airway pressure therapies for obstructive sleep apnoea (OSA). Notably, complete concentric collapse at the level of the palate (CCCp) during drug-induced sleep endoscopy (DISE) is associated with reduced efficacy of hypoglossal nerve stimulation, but CCCp is currently not recognisable using polysomnography. Here we develop a means to estimate DISE-based site of collapse using overnight polysomnography.
Methods: 182 OSA patients provided DISE and polysomnography data. Six polysomnographic flow shape characteristics (mean during hypopnoeas) were identified as candidate predictors of CCCp (primary outcome variable, n=44/182), including inspiratory skewness and inspiratory scoopiness. Multivariable logistic regression combined the six characteristics to predict clear presence (n=22) versus absence (n=128) of CCCp (partial collapse and concurrent tongue base collapse excluded). Odds ratios for actual CCCp between predicted subgroups were quantified after cross-validation. Secondary analyses examined complete lateral wall, tongue base or epiglottis collapse. External validation was performed on a separate dataset (n _total =466).
Results: CCCp was characterised by greater scoopiness (β=1.5±0.6 per 2sd, multivariable estimate±se) and skewness (β=11.4±2.4) compared with non-CCCp. The odds ratio for CCCp in predicted positive versus negative subgroups was 5.0 (95% CI 1.9-13.1). The same characteristics provided significant cross-validated prediction of lateral wall (OR 6.3, 95% CI 2.4-16.5), tongue base (OR 3.2, 95% CI 1.4-7.3) and epiglottis (OR 4.4, 95% CI 1.5-12.4) collapse. CCCp and lateral wall collapse shared similar characteristics (skewed, scoopy), diametrically opposed to tongue base and epiglottis collapse characteristics. External validation confirmed model prediction.
Conclusions: The current study provides a means to recognise patients with likely CCCp or other DISE-based site of collapse categories using routine polysomnography. Since site of collapse influences therapeutic responses, polysomnographic airflow shape analysis could facilitate precision site-specific OSA interventions.
Competing Interests: Conflict of interest: S. Op de Beeck reports grants and travel support from Research Foundation Flanders (FWO). D. Vena receives personal fees as a consultant for Inspire Medical Systems. A. Azarbarzin receives personal fees as a consultant for Somnifix, ZOLL Respicardia, Eli Lilly and Apnimed, and receives grant support from Somnifix, American Heart Association and American Academy of Sleep Medicine; in addition, A. Azarbarzin reports receipt of equipment from Philips Respironics, and the following patents: System and method for endo-phenotyping and risk stratifying obstructive sleep apnea, and Method, non-transitory computer readable medium and apparatus for arousal intensity scoring. P. Huyett is an education consultant for Inspire Medical Systems, and reports grants from Inspire Medical Systems and Nyxoah. J. Verbraecken reports grants and fees from SomnoMed, AstraZeneca, AirLiquide, Atos Medical, Vivisol, Mediq Tefa, Medidis, Micromed OSG, Bioprojet, Desitin, Epilog, Idorsia, Nightbalance, Inspire Medical Systems, Heinen and Löwenstein, Ectosense, Philips, ProSomnus, ResMed, Sefam, SD Worx, SOS Oxygène, Tilman, Total Care, Vlaamse Gemeenschap, Vlerick and ZOLL Itamar, and consultancy for Bioprojet, Idorsia and Epilog. A. Wellman works as a consultant for Apnimed, Somnifix, Inspire, Mosana, Takeda and Nox, and has received grants from the National Institutes of Health, Somnifix and Sanofi; in addition, A. Wellman has a financial interest in Apnimed, a company developing pharmacologic therapies for sleep apnoea, and holds a patent on flow shape analysis to detect the site of airway collapse. O.M. Vanderveken reports research support at Antwerp University Hospital outside the submitted work from ProSomnus, SomnoMed, Philips, Inspire Medical Systems, Nyxoah, Med-El and Cochlear, lecture honoraria from SomnoMed and Inspire Medical Systems, and consultancy for SomnoMed, Inspire Medical Systems and GlaxoSmithKline. S.A. Sands has served as a consultant for Apnimed, Nox Medical, Eli Lilly, Merck, LinguaFlex, Respicardia, Forepont and Inspire Medical, received grant support from Apnimed, ProSomnus, and Dynaflex, received royalties from the licensing of IP for pharmacological therapy for OSA, unrelated to the current study, lecture honoraria from Tufts University, and equipment from Nox Medical; his industry interactions are actively managed by his institution and has the following patents: Co-inventor on a patent for a combination pharmacological therapy therapy and Co-inventor on a patent OSA phenotyping using wearable technology. The remaining authors have not potential conflicts of interest to disclose.
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