Abstract
Aims
Obstructive sleep apnea (OSA) is characterized by episodic sleep state–dependent upper airway collapse. OSA can markedly decrease quality of life (QoL) and productivity. Continuous Positive Airway Pressure (CPAP) has been used as an effective treatment for OSA. Recently, uvulopalatopharyngoplasty (UPPP) treatment has emerged as effective management among patients with OSA, especially non-adherent ones to conventional therapies such as CPAP. Our aim was to determine whether CPAP and UPPP treatment could improve the quality of life in patients with moderate OSA.
Design
Prospective.
Setting
Patients with moderate OSA, confirmed by polysomnography from March 2019 to March 2020, participated. CPAP and UPPP treatments were considered for patients according to their preferences. The Sleep Apnea Quality of Life Index (SAQLI) questionnaire before and after treatment was completed.
Methods
Change in their QoL was compared between the CPAP group and UPPP treatment. In addition, QoL was compared between these groups and patients who did not receive any of these treatment methods.
Results
Seventy-eight patients were included in treatment groups, 40 using CPAP and 38 undergoing UPPP treatment. Furthermore, 10 patients who did not receive treatment were considered the control. Both methods of treatment significantly (p < 0.001) improved QoL, but UPPP treatment was superior (p = 0.042) to CPAP. There was a poor correlation between post-treatment BMI (0.037), Respiratory Disturbance Index (RDI) (0.096), age (0.022), and post-treatment SAQLI score.
Conclusion
Based on these results, CPAP and UPPP treatment can improve QoL. UPPP treatment could be considered an effective arm of OSA management among the study population.
Keywords: Obstructive Sleep Apnea, Quality of Life, CPAP, Surgical Treatment, Uvulopalatopharyngoplasty
Introduction
Sufficient sleep is an essential prerequisite for the effective function of humans. Sleep disorders such as restless leg syndrome and insomnia can impair quality of life (QoL) [1]. Obstructive sleep apnea (OSA) occurs because of the episodic collapse of airways during sleep. OSA can lead to cessation of ventilation, hypoxia, hypercapnia, and eventually arousal from sleep [2]. Patients suffering from OSA will experience several signs and symptoms, such as snoring, inadequate sleep, daytime sleepiness and fatigue, and insomnia. Besides, patients with OSA may feel choking during sleep [1, 3]. Furthermore, OSA is associated with numerous complications. It can result in high blood pressure, cerebrovascular accidents, coronary heart disease, glucose intolerance, sexual impotence, weight gain and obesity, gastroesophageal reflux disease, and concentration problems [1].
A significant proportion of OSA patients are unaware of their condition and its impact on their health status. Hence, they won’t go to a sleep clinic. Additionally, some patients do not consider sleep problems as important complaints and neglect them. Nevertheless, the prevalence of OSA has been estimated to be 3 and 10% among women and men between 30 and 50 years of age, respectively. Its prevalence increases to 9 and 17% among women and men between 50 and 70, respectively [2, 4].
An OSA diagnosis can be confirmed with polysomnography, which detects episodes of breathing difficulties during sleep [5]. Apnea-hypopnea index (AHI) or respiratory disturbance index (RDI) greater than 15 events/hour in asymptomatic individuals or more than five events/hour in symptomatic individuals confirms OSA [6]. AHI between 15 and 30 events/hour suggests moderate OSA, and AHI greater than 30 indicates severe OSA [3].
Lifestyle modification, particularly weight loss, can improve sleep quality [7]. Continuous positive airway pressure (CPAP) has been shown to be one of the most effective treatments for moderate to severe OSA [8]. Previously, it was reported that long-term use of CPAP can considerably improve the QoL of patients with severe OSA [9]. Recently, corrective surgical treatment on nasal, oropharyngeal, and hypopharyngeal airways has been proposed as a safe and effective treatment method for OSA patients [10]. Moreover, studies suggest that surgical treatment can be better than CPAP because of patients’ low compliance with CPAP [11]. There are various types of sleep surgery, but for patients with snoring and sleep apnea, uvulopalatopharyngoplasty (UPPP) is the most common procedure, and our patients underwent this surgical procedure [12]. The present study used a standardized questionnaire to evaluate the effect of CPAP and UPPP treatment on patients with moderate OSA QoL.
Methods
Study Design and Participants
A prospective study was conducted at the Imam Hospital complex of Tehran University of Medical Science from March 2019 to March 2020, providing the data for the present analysis. The sample size was chosen from those patients referring to our sleep clinic and met the inclusion criteria. We followed these inclusion criteria: patients with moderate OSA (AHI or RDI between 15 and 30) confirmed by polysomnography, at least 13 years old, and willing to undergo simultaneous polysomnography (PSG) tests. Patients who did not regularly use CPAP (less than 4 hours/night) and needed more compliance were included in this study. Patients’ informed consent was obtained for participation and publication. According to the Declaration of Helsinki, as revised in 2013, this study followed ethical standards. Furthermore, the ethics committee of Tehran University of Medical Sciences (TUMS) approved the method of this study. At first, eligible patients were advised to undergo CPAP therapy. In cases where patients refused CPAP treatment and preferred surgical intervention, we proceeded with the Drug-induced sleep endoscopy (DISE) procedure. We specifically selected patients with velum obstruction based on the DISE results to undergo UPPP treatment. Finally, eligible patients were divided into three groups: the first group underwent CPAP treatment, the second group received UPPP treatment, and the third group was defined as treated with neither CPAP nor UPPP. The post-operative patients were followed for 6 to 12 months to investigate the outcomes.
Study Measures
Demographic Data
We collected demographic characteristics, including age, gender, marital status, AHI score, RDI (the average respiratory disturbances count (hypopneas, obstructive apneas, and respiratory event–related arousals [RERAs]) per hour), and Body Mass Index (BMI) based on participant self-reports.
Polysomnography
An Embla® N7000 Recording System was used to perform standard PSGs, including electroencephalography (EEG), electrooculography (EOG), electromyography (EMG) of submental and bilateral anterior tibialis, electrocardiography (ECG); nasal pressure transducers were used to measure the nasal airflow, piezoelectric bands were used to measure the abdominal and chest movements, pulse oximetry, snoring, and body position, and infrared beams were used for video monitoring. The PSG data were manually scored according to the guidelines published by the American Academy of Sleep Medicine (AASM) in 2007 to evaluate sleep quality and associated events (16). OSA severity was defined as Mild (5 ≤ AHI < 15), moderate (15 ≤ AHI < 30), and severe (AHI ≥ 30) OSA.
Sleep Apnea Quality of Life Index (SAQLI)
The SAQLI questionnaire was completed for each patient before treatment and six months after treatment. The validity and internal consistency of this questionnaire have been approved previously. It includes 35 items and measures aspects such as social interactions, daily functioning, emotional functioning, symptoms, and negative quality of life impact of treatment side-effects [13].
Statistical Analysis
SPSS software version 22 was used to analyze the data. The Kruskal-Wallis H test was used to compare the effect of both treatment groups with the non-treated group. The Spearman test assessed the correlation between age, BMI, RDI, and post-treatment SAQLI score. Also, QoL was compared between CPAP and surgical treatment using the Mann-Whitney test. Significant differences were defined as those with a probability value lower than 0.05 (p) < 0.05.
Results
Of all individuals referred to our sleep clinic, 88 patients (52.6% of patients consisted of male) with moderate OSA entered this study. Among them, 40 patients used CPAP, 38 underwent UPPP treatment, and 10 did not receive these treatment methods. The RDI was 20.55 ± 7.67 (mean ± SD) among all participants, and BMI was 27.75 ± 3.36 and 27.33 ± 3.12 Kg/m2 before and after treatment, respectively. The prevalence of signs and symptoms are as follows: snoring 58 (74.4%), fatigue 7 (9.0%), daytime sleepiness 6 (7.7%), poor QoL 5 (6.4%), and severe fatigue 2 (2.6%).
CPAP and UPPP treatment significantly (p < 0.001) improved patients’ QoL. We used the Mann-Whitney test to compare the effect of CPAP and UPPP treatment on patients’ QoL. However, the difference was statistically insignificant (p = 0.091) in post-treatment QoL. After removing the outlier values, it was shown that UPPP treatment is significantly superior to CPAP (p = 0.042). In addition, their pre-treatment QoL was not significantly different (P = 0.66).
Additionally, we evaluated the correlation between post-treatment SAQLI score and post-treatment BMI, RDI, and age. Spearman test showed that the correlation is weak between post-treatment BMI (0.037), RDI (0.096), age (0.022), and post-treatment SAQLI score.
Ten patients with moderate OSA who hadn’t received these therapies completed the questionnaire to assess treatment effectiveness. After that, the Kruskal-Wallis H test showed that both CPAP and UPPP treatment could significantly (p < 0.001) improve QoL among patients with moderate OSA.
#Table 1.
Table 1.
Patients’ scores were obtained from the SAQLI questionnaire before and after treatment
| All patients (N = 78) | CPAP (N = 40) | UPPP (N = 38) | P value | |
|---|---|---|---|---|
| SAQLI score before treatment | 54.03 ± 12.94 | 53.58 ± 13.14 | 54.50 ± 12.88 | < 0.001 |
| SAQLI score after treatment | 73.51 ± 12.04 | 71.40 ± 13.06 | 75.74 ± 10.59 | < 0.001 |
Data are presented as mean ± SD. Sleep Apnea Quality of Life Index (SAQLI).
Discussion
In the current study, CPAP and UPPP treatment could significantly improve patients’ QoL with moderate OSA. Furthermore, surgical treatment was superior to CPAP among patients with moderate OSA. Also, the correlation between age, BMI, RDI, and post-treatment SAQLI score was weak. Snoring was the most frequent symptom of OSA among patients with moderate OSA.
OSA negatively affects patients’ QoL and impairs their functionality [14]. Patients with OSA are complicated with cognitive and psychological dysfunction, and obesity, hypertension, diabetes, and cardiovascular diseases are more frequent among these patients. Each of these comorbidities can exacerbate patients’ QoL [15].
Previously, it was observed that CPAP could improve the QoL of patients with severe OSA. CPAP can also improve sleep-related symptoms, anxiety, depression, neurocognitive functions, and brain structure in older adults with severe OSA [16, 17]. Similarly, McMillan et al. revealed that CPAP is more cost-effective than best supportive care (BSC) and improves mobility, sleepiness, mood, cognitive function, functionality, and cardiovascular events. Still, patient groups receiving CPAP and BSC had similar quality-adjusted life years [18]. It was also reported that CPAP could increase survival among elderly patients with moderate to severe OSA [19].
Before the third millennium, CPAP was the main modality for improving OSA patients’ QoL, and there needed to be more data for other treatment modalities [20]. Surgical treatment has recently been widely used for OSA patients, regardless of age. Contrary to surgical treatment, the efficacy of CPAP depends on patients’ compliance, which can reduce its effectiveness [21]. Different surgical treatment methods can be used based on the etiology of their OSA. For instance, it was shown that pediatric OSA is associated with impaired QoL, comparable to juvenile rheumatoid arthritis (JRA). In addition, adenotonsillectomy brings long-term improvement in their QoL [22, 23]. Mandibular advancement is a major type of surgical treatment for OSA patients, particularly in adult patients [24]. CPAP and mandibular advancement had similar efficacy in improving the QoL of OSA patients [25]. Minimally invasive single-stage multilevel surgery (MISS MLS) can increase QoL when conservative treatments for OSA patients do not work [26]. In this regard, UPPP is a surgical method to treat retropalatal regions, and the rate of successful treatment of UPPP ranges from 16 to 83% [27]. It is important to note that lateral pharyngoplasty and barbed reposition pharyngoplasty significantly affect the concepts and methods of palatal surgery [12]. Our results demonstrated that CPAP and UPPP treatment improved the patients’ QOL. Lateral-expansion pharyngoplasty could result in a significant decrease in the AHI from 22.4 ± 27.3 events/hour preoperatively to 13.6 ± 17.9 events/hour after surgery [28]. Also, another interventional surgery known as Transoral Robotic Surgery (TRS) has been reported to improve daytime sleepiness and AHI, as well as the lowest saturation of oxygen in the blood. Blood loss is the most common complication but doesn’t contribute much to intraoperative blood loss. Additionally, this interventional surgery is relatively safe, as the main complication (bleeding) affected 4.2% of patients (range 4.2-5.3%), which is reasonable evidence of its safety. Single-level and multilevel surgery have 68 and 69% success rates, respectively [29–31]. In light of the fact that CPAP is costly and many patients in our region are unable to use CPAP, surgery would be an efficient means of improving our patients’ QoL. There is a need for further research to determine who will have the best surgical outcomes. Furthermore, there is a gap among studies regarding the long-term efficacy of surgery.
The following limitations were considered: The sample size was fairly small, which can lower statistical power. In addition, the outcome measurements were based on patient-reported outcomes, which are prone to reporting bias. We included only patients with moderate severity of OSA, a population-based bias affecting our outcome measurements. Also, UPPP therapy is not the only part of managing patients with OSA; further studies should be conducted to investigate other methods of OSA management.
In conclusion, in this study, both CPAP and UPPP treatment could significantly improve the QoL of patients with moderate OSA, and interestingly, UPPP treatment was better than CPAP in this regard. Further research is needed to determine the effectiveness of upper airway surgery in improving QoL and respiratory events in patients with OSA.
Key Messages
Both UPPP treatment and CPAP could improve the quality of life in OSA patients.
UPPP treatment was considered a better treatment for OSA patients as compared to CPAP treatment.
Acknowledgements
Thanks to the study participants and the research deputy of Tehran University of Medical Sciences for funding the study.
Funding
Tehran University of Medical Sciences supported the study.
Data Availability
Patients’ data are confidential. However, data is available upon request of the journal and ethical considerations.
Declarations
Ethics Approval
The ethical committee of Tehran University of Medical Sciences approved the study (IR.TUMS.IKHC.REC.1398.151).
Consent to Participate
Informed written and oral consent was obtained from study participants.
Consent for Publication
Informed written and oral consent was obtained from study participants to publish their de-identified information.
Conflict of Interest
None.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
Patients’ data are confidential. However, data is available upon request of the journal and ethical considerations.