Sleep apnea patients often report that they sleep better on the couch than in bed. While some of this improvement in sleep quality may result from the absence of an awakening elbow from a frustrated bed partner, it has seemed reasonable to assume that supine sleep is less common on the sofa. The prevalence of supine position-dependent sleep apnea in the general population is unknown, but it is demonstrable in about half of patients suspected of having sleep-disordered breathing referred for a sleep study.1,2 This proportion in even higher in Asian patients.3–5 Compared to patients without position dependence, these patients tend to be less obese, younger, with better sleep quality and less daytime sleepiness.6 It has been argued that since most obstructive sleep apnea (OSA) patients have mild to moderate severity and since position dependence is most prevalent in these categories, the great majority of patients with sleep-disordered breathing demonstrate this pheno-type.7 It is then surprising that treatments, including positional therapy (PT), which are specifically focused on this population have received relatively little attention. This issue of JCSM includes two papers which describe use of PT. In one of these investigations,8 there was little difference between commercially manufactured devices and less elaborate devices (the “tennis ball technique”). Short-term compliance was satisfactory, although long-term use was described as disappointing. Of note, the rate of discontinuation was lowest in patients with mild severity. The second study9 described improved short-term efficacy of a sleep position trainer compared to the tennis ball technique. In both studies, use of PT was effective in decreasing the amount of supine sleep and resulted in decreased measures of OSA severity.
Neither of these studies compared the effectiveness of PT to continuous positive airway pressure (CPAP). A recent systematic review10 found only three studies of satisfactory quality comparing PT with CPAP.11–13 Meta-analysis concluded that CPAP was more effective reducing the apnea-hypopnea index (AHI) and increasing oxyhemoglobin saturation, although the differences were relatively small. The advantage of CPAP was even lower in patients with mild sleep apnea. It is important to emphasize that the definition of position dependence varies among studies. CPAP is generally titrated to an effective level, whereas PT is simply begun. This may make the comparison inherently biased. If sleep in the non-supine position does not result in the absence of pathologic events (i.e., an AHI < 5 events/h), PT will not be as effective as CPAP.7 Patients with mild positional OSA have been shown to have the lowest cardiovascular comorbidities.14 PT should not be recommended for patients who have many events in lateral positions as well as supine. CPAP acceptance is often problematic in patients with mild OSA, particularly in the absence of perceptible daytime sleepiness.15 Therefore, it is reasonable to recommend PT rather than CPAP as initial treatment to patients with mild positional OSA without complaints of excessive sleepiness. The usefulness of PT in patients who refuse or fail to adhere to CPAP is probably minimal.
Unfortunately, an increasingly higher proportion of patients with suspected sleep apnea are referred for in-home sleep testing which may not include a monitor of body position. Consequently, identification of patients with positional OSA is difficult, if not impossible. In patients with mild OSA, it is worth considering performing a follow-up sleep study using PT to demonstrate effectiveness in a particular individual. If PT is shown to be effective, it would be appropriate to emphasize the importance of avoiding supine sleep to the patient utilizing one of the variety of devices described in the literature.16 If PT is not effective, it would be necessary to proceed to some sort of titration of positive airway pressure.
In the final analysis, it comes down to a choice of selecting the most appropriate, cost-effective means of treatment for the unique needs of individual patients rather than subjecting all patients to an uncomfortable and relatively expensive CPAP device, which they often will not use. Additional studies incorporating this holistic approach, incorporating PT, are warranted.
See the papers in this issue on positional therapy on pages 131 and 139.
DISCLOSURE STATEMENT
Dr. Casey has indicated no financial conflicts of interest.
CITATION
Casey KR. Positional therapy is worth a try in patients with mild obstructive sleep apnea. J Clin Sleep Med 2015;11(2):89–90.
REFERENCES
- 1.Oksenberg A, Silverberg DS, Arons E, Radwin H. Positional vs nonpositional obstructive sleep apnea patients: anthropomorphic, nocturnal polysomnographic, and multiple sleep latency test data. Chest. 1997;112:629–39. doi: 10.1378/chest.112.3.629. [DOI] [PubMed] [Google Scholar]
- 2.Mador MJ, Kufel TJ, Magalang UI, et al. Prevalence of positional sleep apnea in patients undergoing polysomnography. Chest. 2005;128:2130–7. doi: 10.1378/chest.128.4.2130. [DOI] [PubMed] [Google Scholar]
- 3.Teerapraipruk B, Chirakawasan N, Simon R, et al. Clinical and polysomnographic data of positional sleep apnea syndrome. Sleep Breath. 2012;16:1167–72. doi: 10.1007/s11325-011-0627-5. [DOI] [PubMed] [Google Scholar]
- 4.Mo JH, Lee C-H, Rhee CS, et al. Positional dependency in Asian patients with obstructive sleep apnea and its implication for hypertension. Arch Otolaryngol Head Neck Surg. 2011;137:786–90. doi: 10.1001/archoto.2011.122. [DOI] [PubMed] [Google Scholar]
- 5.Lee C-H, Jung HJ, Lee WH, et al. The effect of positional dependency on outcomes of treatment with a mandibular advancement device. Arch Otolaryngol Head Neck Surg. 2012;138:479–83. doi: 10.1001/archoto.2012.452. [DOI] [PubMed] [Google Scholar]
- 6.Joosten SA, O'Driscoll DM, Berger PJ, Hamilton GS. Supine position related obstructive sleep apnea in adults: pathogenesis and treatment. Sleep Med Rev. 2014;18:7–17. doi: 10.1016/j.smrv.2013.01.005. [DOI] [PubMed] [Google Scholar]
- 7.Oksenberg AS. Positional therapy for sleep apnea: a promising behavioral therapeutic option still waiting for qualified studies. Sleep Med Rev. 2014;18:3–5. doi: 10.1016/j.smrv.2013.08.003. [DOI] [PubMed] [Google Scholar]
- 8.de Vries GE, Hoekema A, Doff MH, et al. Usage of positional therapy in adults with obstructive sleep apnea. J Clin Sleep Med. 2015;11:131–7. doi: 10.5664/jcsm.4458. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Eijsvogel MH, Ubbink R, Dekker J, et al. Sleep position trainer versus tennis ball technique in positional obstructive sleep apnea syndrome. J Clin Sleep Med. 2015;11:139–47. doi: 10.5664/jcsm.4460. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Ha SC, Hirai HW, Tsoi KK. Comparison of positional therapy versus continuous positive airway pressure in patients with positional obstructive sleep apnea: a meta-analysis of randomized trials. Sleep Med Rev. 2014;18:19–24. doi: 10.1016/j.smrv.2013.05.003. [DOI] [PubMed] [Google Scholar]
- 11.Permut I, Diaz-Abad M, Chatila W, et al. Comparison of positional therapy to CPAP in patients with positional obstructive sleep apnea. J Clin Sleep Med. 2010;6:238–43. [PMC free article] [PubMed] [Google Scholar]
- 12.Skinner MA, Kingshott RN, Filsell S, et al. Efficacy of the “tennis ball technique” versus nCPAP in the mgmt. of position-dependent obstructive sleep apnoea syndrome. Respirology. 2008;13:708–13. doi: 10.1111/j.1440-1843.2008.01328.x. [DOI] [PubMed] [Google Scholar]
- 13.Jokic R, Klimaszewski A, Crossley M, et al. Positional treatment vs continuous positive airway pressure in patients with positional obstructive sleep apnea syndrome. Chest. 1999;115:771–81. doi: 10.1378/chest.115.3.771. [DOI] [PubMed] [Google Scholar]
- 14.Huang YC, Lin CC, Wu YK, et al. Comparison of cardiovascular co-morbidities and CPAP use in patients with positional and non-positional mild obstructive sleep apnea. BMC Pulm Med. 2014;14:153. doi: 10.1186/1471-2466-14-153. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.McArdle N, Devereux G, Heidarnejad H, et al. Long-term use of CPAP therapy for sleep apnea/hypopnea syndrome. Am J Respir Crit Care Med. 1999;159:1108–14. doi: 10.1164/ajrccm.159.4.9807111. [DOI] [PubMed] [Google Scholar]
- 16.Ravesloot MJL, Van Maanen JP, Dun L, et al. The undervalued potential of positional therapy in position-dependent snoring and obstructive sleep apnea—a review of the literature. Sleep Breath. 2013;17:39–49. doi: 10.1007/s11325-012-0683-5. [DOI] [PMC free article] [PubMed] [Google Scholar]