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.
Follow-Up
After completion of the initial therapeutic pathway, patients continue to follow up regularly, monitoring for AEs from UAS therapy and sleep apnea symptoms. Patients can be followed in the nonsurgical sleep clinic after the initial postoperative appointment with the surgeon. Frequency of follow-up depends on the presence and severity of any AEs and residual symptoms of sleep apnea. Even though most AEs related to UAS therapy reported in the STAR trial were nonserious and transient, 2% of participants required surgical revision.3 Therefore, maintaining open channels of communication among the entire UAS patient care team even months and years after surgical implantation is important. The nonsurgical sleep medicine physician who will continue to monitor the patient’s progress may need to consult with the surgical colleague or industry liaison at any point during treatment.
Limitations
This review outlines the UAS therapy pathway and emphasizes the role of the nonsurgical sleep medicine provider. However, the experience describes a UAS program development at a single VA medical center. Since this UAS device and therapy have already been approved by the VA on a national level, we did not face any challenges with authorization and insurance compensation. Therefore, this review does not provide any guidance with these matters. These are certainly common concerns for sleep medicine providers who offer UAS therapy in medical practices outside the VA, and these would hopefully be addressed in the future.
Furthermore, this review is based on the pulmonary sleep medicine provider’s experience and perspective. Therefore, certain aspects of UAS therapy could be better addressed by nonsurgical sleep medicine providers in different fields of expertise. For example, a study by a psychiatrist or psychologist could provide insight into the emotional concerns of patients who are undergoing this novel and life-altering treatment that includes surgical implantation of hardware into the body. A neurologist could explore the long-term effects of recurrent electrical stimulation on the autonomic and somatic nervous system as well as the musculature of the upper airway.
Conclusion
Multidisciplinary perspectives are needed to provide guidance for practitioners and institutions looking to set up and improve established UAS programs. As the long-term outcomes of the STAR trial continue to be published and provide more validation for UAS, this novel therapy will likely continue to gain acceptance as a safe and effective treatment for OSA.11
