Hypoglossal Nerve Stimulation: A New Treatment Approach for Obstructive Sleep Apnea. A Review
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Mar 22, 2014
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Abstract
Introduction: Obstructive Sleep Apnea (OSA) is the most common sleep respiratory disorder. Although Continuous Positive Airway Pressure (CPAP) is the treatment of choice, it has poor adherence. The Hypoglossal Nerve Stimulation (HNS) is being studied as a new therapeutic approach.
Objective: To review the pathophysiology of this disorder and the effectiveness
and safety of HNS as a treatment for OSA.
Methods: Information was retrieved from the database Medline using the search terms: Sleep Apnea, Syndrome; Sleep Apnea, Obstructive; Hypoglossal Nerve; Electrodes, Implanted; Implantable Neurostimulators, and Electric Stimulation Therapy.
Results: 267 articles were found, of which 27 met the inclusion and exclusion
criteria. In addition, a secondary search from these articles was performed. The HNS has shown a favorable effectiveness and safety profile with a high adherence as a treatment for OSA. However, it is not recommended for patients with an Apnea-Hypopnea Index >50 since it only causes a partial reduction of the AHI; a less effective result than the one observed with CPAP.
Conclusion: The HNS partially improves one of the pathophysiological mechanisms of OSA. In this review, the data shows an acceptable effectiveness and safety profile in short-term, but more research is needed on the long-term effectiveness and safety of HNS as well as the bilateral use of this new therapy and a clinical study comparing it with CPAP.
Keywords
apnea del sueño obstructiva, nervio hipogloso, terapia por estimulación eléctrica, Sleep apnea, obstructive, hypoglossal nerve, electric stimulation therapy,
References
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of upper airway mechanics
during sleep. Respir Physiol Neurobiol.
2008;163(1-3):74-81.
2. Akinnusi M, Saliba R, El-Solh A. Emerging
therapies for obstructive sleep apnea.
Lung. 2012;190(4):365-71.
3. Eastwood P, Barnes M, Walsh J et al.
Treating obstructive sleep apnea with
hypoglossal nerve stimulation. Sleep.
2011;34(11):1479-86.
4. Verbraecken J, De backer W. Upper airway
mechanics. Respiration. 2009;78(2):
121-33.
5. Remmers J, deGroot W, Sauerland E,
Anch A. Pathogenesis of upper airway
occlusion during sleep. J Appl Physiol.
1978;44:931-8.
6. Gastaut H, Tassinari C, Duron B. Polygraphic
study of diurnal and nocturnal
(hypnic and respiratory) episodal manifestations
of Pickwick syndrome. Rev
Neurol (Paris). 1965;112:568-79.
7. Ryan C, Bradley T. Pathogenesis of obstructive
sleep apnea. J Appl Physiol.
2005;99(6):2440-50.
8. Dubois A. Airway resistance. Am J
Respir Crit Care Med. 2000;162(2 Pt
1):345-6.
9. Schwartz A, Bennett M, Smith P et al.
Therapeutic electrical stimulation of the
hypoglossal nerve in obstructive sleep
apnea. Arch Otolaryngol Head Neck
Surg. 2001;127(10):1216-23.
10. Georgalas C. The role of the nose in
snoring and obstructive sleep apnoea:
an update. Eur Arch Otorhinolaryngol.
2011;268(9):1365-73.
11. Rowley J, Permutt S, Willey S et al. Effect of tracheal and tongue displacement on upper airway airflow dynamics. J Appl Physiol. 1996;80:2171-8.
12. Dempsey J, Veasey S, Morgan B, O‘Donnell C. Pathophysiology of sleep apnea. Physiol Rev. 2010;90(1):47-112.
13. Oliven A, O‘Hearn D, Boudewyns A et al. Upper airway response to electrical stimulation of the genioglossus in obstructive sleep apnea. J Appl Physiol. 2003;95(5):2023-9.
14. Oliven A. Treating obstructive sleep apnea with hypoglossal nerve stimulation. Curr Opin Pulm Med. 2011;17(6):419-24.
15. Kribbs N, Pack A, Kline L et al. Objective measurement of patterns of nasal CPAP use by patients with obstructive sleep apnea. Am Rev Respir Dis. 1993; 147(4):887-95.
16. Kezirian E, Boudewyns A, Eisele D et al. Electrical stimulation of the hypoglossal nerve in the treatment of obstructive sleep apnea. Sleep Med Rev. 2010;5:299-305.
17. Pierce R, Worsnop C. Upper airway function and dysfunction in respiration. Clin Exp Pharmacol Physiol. 1999;26(1):1-10.
18. Howard BK, Rohrich RJ. Understanding the nasal airway: principles and practice. Plast Reconstr Surg. 2002;109(3):1128-46.
19. Kaminsky DA. What does airway resistance tell us about lung function? Respir Care. 2012;57(1):85-96.
20. Sériès F. Upper airway muscles awake and asleep. Sleep Med Rev. 2002;6(3):229-42.
21. Cosío B, Rodríguez Rosado J. [Importance of the distal airway in COPD]. Arch Bronconeumol. 2011;47 Suppl 2:32-7.
22. White D. Pathogenesis of obstructive and central sleep apnea. Am J Respir Crit Care Med. 2005;172:1363-70.
23. Eckert D, Malhotra A. Pathophysiology of adult obstructive sleep apnea. Proc Am Thorac Soc. 2008;5:144-53.
24. Eisele D, Schwartz A, Hari A et al. The effects of selective nerve stimulation on upper airway airflow mechanics. Arch Otolaryngol Head Neck Surg. 1995;121:1361-4.
25. Bishara H, Odeh M, Schnall R et al. Electrically-activated dilator muscles reduce pharyngeal resistance in anaesthetized dogs with upper airway obstruction. Eur Respir J. 1995;8:1537-42.
26. Dotan Y, Golibroda T, Oliven R et al. Parameters affecting pharyngeal response to genioglossus stimulation in sleep apnoea. Eur Respir J. 2011;38:338-47.
27. Oliven A, Schnall R, Odeh M. Improved upper airway patency elicited by electrical stimulation of the hypoglossus nerves. Respiration. 1996;63:213-6.
28. Schwartz A, Thut D, Russ B et al. Effect of electrical stimulation of the hypoglossal nerve on airflow mechanics in the isolated upper airway. Am Rev Respir Dis. 1993;147:1144-50.
29. Kuna ST. Regional effects of selective pharyngeal muscle activation on airway shape. Am J Respir Crit Care Med. 2004;169(9):1063-9.
30. Bellemare F, Pecchiari M, Bandini M et al. Reversibility of airflow obstruction by hypoglossus nerve stimulation in anesthetized rabbits. Am J Respir Crit Care Med. 2005;172:606-12.
31. Fregosi R. Influence of tongue muscle contraction and dynamic airway pressure on velopharyngeal volume in the rat. J Appl Physiol. 2008;104:682-93.
32. Yoo P, Durand D. Effects of selective hypoglossal nerve stimulation on canine upper airway mechanics. J Appl Physiol. 2005;99:937-43.
33. Goding G, Eisele D, Testerman R et al. Relief of upper airway obstruction with hypoglossal nerve stimulation in the canine. Laryngoscope. 1998;108:162-9.
34. Miki H, Hida W, Inoue H et al. A new treatment for obstructive sleep apnea syndrome by electrical stimulation of submental region. Tohoku J Exp Med. 1988;154(1):91-2.
35. Hida W, Okabe S, Miki H et al. Effects of submental stimulation for several consecutive nights in patients with obstructive sleep apnoea. Thorax. 1994;49(5):446-52.
36. Isono S, Tanaka A, Nishino T. Effects of tongue electrical stimulation on pharyngeal mechanics in anaesthetized patients with obstructive sleep apnoea. Eur Respir J. 1999;14(6):1258-65.
37. Huang J, Sahin M, Durand DM. Dilation of the oropharynx via selective stimulation of the hypoglossal nerve. J Neural Eng. 2005;2(4):73-80.
38. Oliven A, O‘Hearn D, Boudewyns A et al. Upper airway response to electrical stimulation of the genioglossus in obstructive sleep apnea. J Appl Physiol. 2003;95(5):2023-9.
39. Oliven A, Tov N, Geitini L, Steinfeld U, Oliven R, Schwartz A. Effect of genioglossus contraction on pharyngeal lumen and airflow in sleep apnoea patients. Eur Respir J. 2007;30:748-58.
40. Randerath WJ, Galetke W, Domanski U et al. Tongue-muscle training by intraoral electrical neurostimulation in patients with obstructive sleep apnea. Sleep. 2004;27(2):254-9.
41. Decker M, Haaga J, Arnlod JL et al. Functional electrical stimulation and respiration during sleep. J Appl Physiol. 1993;75:1053-61.
42. Miki H, Hida W, Chonan T et al. Effects of submental electrical stimulation during sleep on upper airway patency in patients with obstructive sleep apnea. Am Rev Respir Dis. 1989;140:1285-9.
43. Schwartz A, Eisele DW, Hari A et al. Electrical stimulation of the lingual musculature in obstructive sleep apnea. J Appl Physiol. 1996;81:643-52.
44. Smith P, Eisele D, Podszus T et al. Electrical stimulation of upper airway musculature. Sleep 1996;19(10):S284-7.
45. Oliven A, Tov N, Geitini L et al. Effect of genioglossus contraction on pharyngeal lumen and airflow in sleep apnoea patients. Eur Respir J. 2007;30(4):748-58.
46. Oliven R, Tov N, Odeh M et al. Interacting effects of genioglossus stimulation and mandibular advancement in sleep apnea. J Appl Physiol. 2009;106(5):1668-73.
47. Oliven A, Kaufman E, Kaynan R et al. Mechanical parameters determining pharyngeal collapsibility in patients with sleep apnea. J Appl Physiol. 2010; 109: 1037-44.
48. Dotan Y, Golibroda T, Netzer A, Oliven A. Interaction between tongue movement and velopharyngeal size and stability during genioglossus stimulation in patients with obstructive sleep apnea. Am J Respir Crit Care Med. 2011;183:A2725.
49. Schwartz A, Barnes M, Hillman D et al. Acute upper airway responses to hypoglossal nerve stimulation during sleep in obstructive sleep apnea. Am J Respir Crit Care Med. 2012;185(4):420-6.
50. Badr M, Oliven A, Maurer J. Predictor of response for upper airway stimulation in obstructive sleep apnea. Am J Respir Crit Care Med. 2011;183:A2727.
51. Mwenge G, Rombaux P, Dury M et al. Targeted hypoglossal neurostimulation for obstructive sleep apnoea: a 1-year pilot study. Eur Respir J. 2013;41(2):360-7.
52. Barbé F, Masa JF. Hypoglossal neurostimulation for obstructive sleep apnoea. Eur Respir J. 2013;41(2):257-8.
53. Rodenstein D, Rombaux P, Lengele B et al. Residual effect of THN hypoglossal stimulation in obstructive sleep apnea: a disease-modifying therapy. Am J Respir Crit Care Med. 2013;187(11):1276-8.
of upper airway mechanics
during sleep. Respir Physiol Neurobiol.
2008;163(1-3):74-81.
2. Akinnusi M, Saliba R, El-Solh A. Emerging
therapies for obstructive sleep apnea.
Lung. 2012;190(4):365-71.
3. Eastwood P, Barnes M, Walsh J et al.
Treating obstructive sleep apnea with
hypoglossal nerve stimulation. Sleep.
2011;34(11):1479-86.
4. Verbraecken J, De backer W. Upper airway
mechanics. Respiration. 2009;78(2):
121-33.
5. Remmers J, deGroot W, Sauerland E,
Anch A. Pathogenesis of upper airway
occlusion during sleep. J Appl Physiol.
1978;44:931-8.
6. Gastaut H, Tassinari C, Duron B. Polygraphic
study of diurnal and nocturnal
(hypnic and respiratory) episodal manifestations
of Pickwick syndrome. Rev
Neurol (Paris). 1965;112:568-79.
7. Ryan C, Bradley T. Pathogenesis of obstructive
sleep apnea. J Appl Physiol.
2005;99(6):2440-50.
8. Dubois A. Airway resistance. Am J
Respir Crit Care Med. 2000;162(2 Pt
1):345-6.
9. Schwartz A, Bennett M, Smith P et al.
Therapeutic electrical stimulation of the
hypoglossal nerve in obstructive sleep
apnea. Arch Otolaryngol Head Neck
Surg. 2001;127(10):1216-23.
10. Georgalas C. The role of the nose in
snoring and obstructive sleep apnoea:
an update. Eur Arch Otorhinolaryngol.
2011;268(9):1365-73.
11. Rowley J, Permutt S, Willey S et al. Effect of tracheal and tongue displacement on upper airway airflow dynamics. J Appl Physiol. 1996;80:2171-8.
12. Dempsey J, Veasey S, Morgan B, O‘Donnell C. Pathophysiology of sleep apnea. Physiol Rev. 2010;90(1):47-112.
13. Oliven A, O‘Hearn D, Boudewyns A et al. Upper airway response to electrical stimulation of the genioglossus in obstructive sleep apnea. J Appl Physiol. 2003;95(5):2023-9.
14. Oliven A. Treating obstructive sleep apnea with hypoglossal nerve stimulation. Curr Opin Pulm Med. 2011;17(6):419-24.
15. Kribbs N, Pack A, Kline L et al. Objective measurement of patterns of nasal CPAP use by patients with obstructive sleep apnea. Am Rev Respir Dis. 1993; 147(4):887-95.
16. Kezirian E, Boudewyns A, Eisele D et al. Electrical stimulation of the hypoglossal nerve in the treatment of obstructive sleep apnea. Sleep Med Rev. 2010;5:299-305.
17. Pierce R, Worsnop C. Upper airway function and dysfunction in respiration. Clin Exp Pharmacol Physiol. 1999;26(1):1-10.
18. Howard BK, Rohrich RJ. Understanding the nasal airway: principles and practice. Plast Reconstr Surg. 2002;109(3):1128-46.
19. Kaminsky DA. What does airway resistance tell us about lung function? Respir Care. 2012;57(1):85-96.
20. Sériès F. Upper airway muscles awake and asleep. Sleep Med Rev. 2002;6(3):229-42.
21. Cosío B, Rodríguez Rosado J. [Importance of the distal airway in COPD]. Arch Bronconeumol. 2011;47 Suppl 2:32-7.
22. White D. Pathogenesis of obstructive and central sleep apnea. Am J Respir Crit Care Med. 2005;172:1363-70.
23. Eckert D, Malhotra A. Pathophysiology of adult obstructive sleep apnea. Proc Am Thorac Soc. 2008;5:144-53.
24. Eisele D, Schwartz A, Hari A et al. The effects of selective nerve stimulation on upper airway airflow mechanics. Arch Otolaryngol Head Neck Surg. 1995;121:1361-4.
25. Bishara H, Odeh M, Schnall R et al. Electrically-activated dilator muscles reduce pharyngeal resistance in anaesthetized dogs with upper airway obstruction. Eur Respir J. 1995;8:1537-42.
26. Dotan Y, Golibroda T, Oliven R et al. Parameters affecting pharyngeal response to genioglossus stimulation in sleep apnoea. Eur Respir J. 2011;38:338-47.
27. Oliven A, Schnall R, Odeh M. Improved upper airway patency elicited by electrical stimulation of the hypoglossus nerves. Respiration. 1996;63:213-6.
28. Schwartz A, Thut D, Russ B et al. Effect of electrical stimulation of the hypoglossal nerve on airflow mechanics in the isolated upper airway. Am Rev Respir Dis. 1993;147:1144-50.
29. Kuna ST. Regional effects of selective pharyngeal muscle activation on airway shape. Am J Respir Crit Care Med. 2004;169(9):1063-9.
30. Bellemare F, Pecchiari M, Bandini M et al. Reversibility of airflow obstruction by hypoglossus nerve stimulation in anesthetized rabbits. Am J Respir Crit Care Med. 2005;172:606-12.
31. Fregosi R. Influence of tongue muscle contraction and dynamic airway pressure on velopharyngeal volume in the rat. J Appl Physiol. 2008;104:682-93.
32. Yoo P, Durand D. Effects of selective hypoglossal nerve stimulation on canine upper airway mechanics. J Appl Physiol. 2005;99:937-43.
33. Goding G, Eisele D, Testerman R et al. Relief of upper airway obstruction with hypoglossal nerve stimulation in the canine. Laryngoscope. 1998;108:162-9.
34. Miki H, Hida W, Inoue H et al. A new treatment for obstructive sleep apnea syndrome by electrical stimulation of submental region. Tohoku J Exp Med. 1988;154(1):91-2.
35. Hida W, Okabe S, Miki H et al. Effects of submental stimulation for several consecutive nights in patients with obstructive sleep apnoea. Thorax. 1994;49(5):446-52.
36. Isono S, Tanaka A, Nishino T. Effects of tongue electrical stimulation on pharyngeal mechanics in anaesthetized patients with obstructive sleep apnoea. Eur Respir J. 1999;14(6):1258-65.
37. Huang J, Sahin M, Durand DM. Dilation of the oropharynx via selective stimulation of the hypoglossal nerve. J Neural Eng. 2005;2(4):73-80.
38. Oliven A, O‘Hearn D, Boudewyns A et al. Upper airway response to electrical stimulation of the genioglossus in obstructive sleep apnea. J Appl Physiol. 2003;95(5):2023-9.
39. Oliven A, Tov N, Geitini L, Steinfeld U, Oliven R, Schwartz A. Effect of genioglossus contraction on pharyngeal lumen and airflow in sleep apnoea patients. Eur Respir J. 2007;30:748-58.
40. Randerath WJ, Galetke W, Domanski U et al. Tongue-muscle training by intraoral electrical neurostimulation in patients with obstructive sleep apnea. Sleep. 2004;27(2):254-9.
41. Decker M, Haaga J, Arnlod JL et al. Functional electrical stimulation and respiration during sleep. J Appl Physiol. 1993;75:1053-61.
42. Miki H, Hida W, Chonan T et al. Effects of submental electrical stimulation during sleep on upper airway patency in patients with obstructive sleep apnea. Am Rev Respir Dis. 1989;140:1285-9.
43. Schwartz A, Eisele DW, Hari A et al. Electrical stimulation of the lingual musculature in obstructive sleep apnea. J Appl Physiol. 1996;81:643-52.
44. Smith P, Eisele D, Podszus T et al. Electrical stimulation of upper airway musculature. Sleep 1996;19(10):S284-7.
45. Oliven A, Tov N, Geitini L et al. Effect of genioglossus contraction on pharyngeal lumen and airflow in sleep apnoea patients. Eur Respir J. 2007;30(4):748-58.
46. Oliven R, Tov N, Odeh M et al. Interacting effects of genioglossus stimulation and mandibular advancement in sleep apnea. J Appl Physiol. 2009;106(5):1668-73.
47. Oliven A, Kaufman E, Kaynan R et al. Mechanical parameters determining pharyngeal collapsibility in patients with sleep apnea. J Appl Physiol. 2010; 109: 1037-44.
48. Dotan Y, Golibroda T, Netzer A, Oliven A. Interaction between tongue movement and velopharyngeal size and stability during genioglossus stimulation in patients with obstructive sleep apnea. Am J Respir Crit Care Med. 2011;183:A2725.
49. Schwartz A, Barnes M, Hillman D et al. Acute upper airway responses to hypoglossal nerve stimulation during sleep in obstructive sleep apnea. Am J Respir Crit Care Med. 2012;185(4):420-6.
50. Badr M, Oliven A, Maurer J. Predictor of response for upper airway stimulation in obstructive sleep apnea. Am J Respir Crit Care Med. 2011;183:A2727.
51. Mwenge G, Rombaux P, Dury M et al. Targeted hypoglossal neurostimulation for obstructive sleep apnoea: a 1-year pilot study. Eur Respir J. 2013;41(2):360-7.
52. Barbé F, Masa JF. Hypoglossal neurostimulation for obstructive sleep apnoea. Eur Respir J. 2013;41(2):257-8.
53. Rodenstein D, Rombaux P, Lengele B et al. Residual effect of THN hypoglossal stimulation in obstructive sleep apnea: a disease-modifying therapy. Am J Respir Crit Care Med. 2013;187(11):1276-8.
How to Cite
Pérez García, I. C., Salcedo Betancourt, J. D., Ríos Rosado, E. C., Ruiz Morales, Álvaro J., Ospina García, J. C., & Hidalgo Martínez, P. (2014). Hypoglossal Nerve Stimulation: A New Treatment Approach for Obstructive Sleep Apnea. A Review. Universitas Medica, 55(3), 286–296. https://doi.org/10.11144/Javeriana.umed55-3.enhn
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