Phenotypic Labelling Using Drug-Induced Sleep Endoscopy Improves Patient Selection for Mandibular Advancement Device Outcome: A Prospective Study

Abstract

Study objectives: Mandibular advancement device (MAD) outcome varies between patients. We hypothesized that upper airway collapse sites, patterns, and degrees assessed during baseline drug-induced sleep endoscopy (DISE) affect MAD outcome.

Methods: One hundred patients with obstructive sleep apnea (OSA) were included and underwent baseline type 1 polysomnography. MAD was fitted intraorally at fixed 75% maximal protrusion. A total of 72 patients completed 3-month follow-up polysomnography and baseline DISE. Response was defined as apnea-hypopnea index (AHI) reduction ≥ 50%, deterioration as AHI increases during MAD treatment compared to baseline.

Results: Adjusting for baseline AHI and body mass index, patients with tongue base collapse showed 3.69 higher odds (1.27-10.73; P = .0128) for response. Complete concentric collapse at the level of the palate (5.32 [1.21-23.28]; P = .0234) and complete laterolateral oropharyngeal collapse (6.62 [1.14-38.34]; P = .0330) related to deterioration. Results for tongue base collapse and complete concentric collapse at the level of the palate were confirmed in the moderate to severe OSA subgroup. Applying these results to this selected subgroup increased response rate with 54% and decreased deterioration rate with 53%. These results were confirmed using other response and deterioration definitions.

Conclusions: Three baseline DISE phenotypes identified during drug-induced sleep were significantly related to MAD treatment outcome: one beneficial, tongue base collapse, and two adverse, complete concentric collapse at the level of the palate and complete laterolateral oropharyngeal collapse. If confirmed in future prospective studies, these results could guide patient selection for MAD outcome.

Clinical trial registration: This prospective clinical trial (PROMAD) was registered on Clinicaltrials.gov with identifier: NCT01532050.

Citation: Op de Beeck S, Dieltjens M, Verbruggen AE, Vroegop AV, Wouters K, Hamans E, Willemen M, Verbraecken J, De Backer WA, Van de Heyning PH, Braem MJ, Vanderveken OM. Phenotypic labelling using drug-induced sleep endoscopy improves patient selection for mandibular advancement device outcome: a prospective study. J Clin Sleep Med. 2019;15(8):1089-1099.

Keywords: DISE; MAD; OSA; obstructive sleep apnea; personalized medicine.

Figure 1. Timeline study protocol (A) and patient flow (B).

The patient flow for all study patients (baseline AHI ≥ 5 events/h) is shown in arm 1, the patient flow for patients with moderate to severe obstructive sleep apnea (baseline AHI ≥ 15 events/h) is shown in arm 2. Reasons for dropout are given in the supplemental material. AHI = apnea-hypopnea index, DISE = drug-induced sleep endoscopy, MAD = mandibular advancement device, PSG = polysomnography.

Figure 2. Standard scoring system for DISE.

Rows represent the site of upper airway collapse, columns represent level, degree and direction. Originally published in Verbruggen et al. Reprinted with permission from the American Academy of Dental Sleep Medicine. Available from: http://dx.doi.org/10.15331/jdsm.6250. DISE = drug-induced sleep endoscopy.

Figure 3. Distribution for degree and direction of collapse in patients with palatal collapse.

Number of responders shown in brackets. Three patients could not be classified in this Venn diagram as they showed doubtful complete concentric collapse at the level of the palate (CCCp) (2 complete collapse, of which 1 responder and 1 partial collapse, of which 1 responder). Venn diagrams for the other collapse sites are shown in the supplemental material (Figure S2).

Figure 4. Change in AHI for each participant.

Change in AHI for each participant with (left) and without (right) tongue base collapse, complete concentric collapse at the level of the palate and complete laterolateral oropharyngeal collapse, taken into account all patients (left column) or only patients with baseline AHI ≥ 15 (right column). Outliers were omitted in this graphical representation. * P < .05, ** P < .01, *** P < .0001. AHI = apnea-hypopnea index, CCCp = complete concentric collapse at the level of the palate, CLLCop = complete laterolateral oropharyngeal collapse, MAD = mandibular advancement device.