The Nonsurgical Sleep Medicine Physician Role in the Development of an Upper Airway Stimulation Program
Background: Obstructive sleep apnea (OSA) is a common disorder in the US and other industrialized countries. Untreated OSA is associated with increased risk of coronary artery disease, cerebrovascular accidents, uncontrolled diabetes mellitus, poor workplace productivity, increased health care utilization, and higher risk of motor vehicle accidents. Continuous positive airway pressure (CPAP) is a commonly used treatment for OSA. CPAP nonadherence continues to be a major problem in clinical practice.
Methods: Upper airway stimulation (UAS) is an alternative option for management of OSA and has been shown to be safe and effective. This therapy involves electrical stimulation of the hypoglossal nerve to facilitate airway opening in the oropharynx.
Results: Although the UAS device is implanted by a surgeon in the operating room, the nonsurgical sleep medicine provider can play an important role in this type of therapy.
Conclusions: This article outlines opportunities for a nonsurgical physician to become a leader in development of an institutional UAS program.
Drug-Induced Sedated Endoscopy
Patient pathway to neurostimulator implantation involves evaluation of the upper airway using drug-induced sedated endoscopy (DISE). This procedure helps determine whether the patient’s anatomy is appropriate for UAS. DISE also can evaluate the pattern of airway closure during an apneic episode. Anterior-posterior pattern of closure is associated with greater UAS effectiveness compared with concentric pattern of airway closure. DISE is typically performed by the otolaryngologist scheduled to implant the UAS. However, nonsurgical physicians who are part of the patient’s care team can be trained to perform this procedure especially if they have experience in performing endoscopy of the upper airway (such as a pulmonary specialist). This can make the evaluation process more efficient and dramatically improve access to care.
Coordination of Care
In order for the UAS program to be successful, the patient’s care team has to work closely with the device manufacturer throughout the implantation pathway and for ongoing patient care. The device manufacturer can assist with education of HCPs, surgical physicians, clinical support staff, and the patient. However, an even more essential role for industry support is during UAS device activation and subsequent titration of UAS via an overnight in-laboratory sleep study.
After surgical implantation, the UAS device activation can be performed in the nonsurgical sleep clinic and is done about 1 month later. This period allows for tissue healing after the surgery and for the patient to get accustomed to having this new device in their body. This activation can be done with assistance from an industry technician until the HCP is comfortable with this process. The multidisciplinary UAS team could choose to delegate device activation to a technician with specialized relevant training, such as RPSGT or respiratory therapist (RT).
This procedure involves determination of sensory and functional threshold for UAS. Sensory threshold is minimum voltage required for the patient to feel the stimulation. The functional threshold is the minimum voltage required to move the tongue past the lower front teeth during stimulation. After these thresholds are established, a voltage range is set on the device. The voltage at functional threshold is typically set at the lower level of this range, and the maximum level is set at 1 volt higher. Patients are able to adjust voltage within this range and are instructed to increase the voltage gradually (0.1-volt increments) while maintaining levels that are comfortable during sleep.
About a month after device activation, patients undergo another overnight polysomnogram for titration of UAS device. In order to educate and train the institutional RPSGT on how to perform this type of titration, an industry technician is required for the first few overnight titrations. The goal of this study is to establish appropriate voltage to resolve sleep-disordered breathing and insure patient comfort at this setting. Patients typically leave the study with a new voltage range. They are asked to keep effective voltage in mind and make appropriate adjustments to maintain comfortable therapy.
Successful UAS therapy includes multiple steps, such as implantation, activation, and titration. This protocol requires effective coordination of care that includes communication with surgical staff, patients, support staff, and industry liaison. Nonsurgical sleep medicine physicians can play a vital role by helping to coordinate care at the early stages of UAS therapy and facilitate effective communication among various providers involved in this process.
