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Unpredictable Results of Laser Assisted Uvulopalatoplasty in the Treatment

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Unpredictable Results of Laser Assisted Uvulopalatoplasty in the Treatment Thorax 2000;55:399–404 399 Unpredictable results of laser assisted uvulopalatoplasty in the treatment of obstructive Thorax: first published as 10.1136/thorax.55.5.399 on 1 May 2000. Downloaded from sleep apnoea CFRyan,LLLove Abstract its eYcacy,23 LAUP has gained additional Background—Laser assisted uvulopalato- popularity as a treatment for obstructive sleep plasty (LAUP) is increasingly oVered for apnoea (OSA).4–11 The diYculty in distinguish- the treatment of obstructive sleep apnoea ing between simple snoring and OSA on clini- (OSA), although there is a lack of objec- cal grounds alone,12–15 coupled with the appar- tive data to support its indications and ent infrequency with which preoperative sleep eYcacy. A study was undertaken to deter- monitoring is performed, has raised concerns mine the treatment response to LAUP. about LAUP as a treatment for OSA.3 Patients Methods—Overnight polysomnography may be undergoing this surgical procedure for was performed before and at least three the treatment of simple snoring without due months after surgery in 44 consecutive regard for its potential impact on any associ- patients with symptomatic mild to moder- ated sleep disordered breathing. The limited ate OSA (apnoea + hypopnoea index available data on sleep monitoring before and (AHI) >10/h). Pharyngeal dimensions after LAUP, derived from studies with small were measured by videoendoscopy (n = sample sizes, suggest that the objective eYcacy 11) and disease-specific quality of life, of LAUP in patients with OSA is no better than 4 sleepiness and snoring frequency (n = 16) uvulopalatopharyngoplasty (UPPP). Of par- before and after surgery were determined ticular concern is the possibility that LAUP in subgroups of patients. LAUP was might actually cause worsening of OSA in 5 performed under local anaesthesia as a some patients. one stage resection of the uvula and soft The primary purpose of this study was to palate by one of two experienced otolaryng- measure the objective eYcacyofLAUPinthe ologists. treatment of OSA. We also wished to examine Results—Twelve patients (27%) had a the impact of LAUP on quality of life, daytime sleepiness, and severity of snoring. In addition, good response (AHI <10/h after LAUP); http://thorax.bmj.com/ four (9%) had a partial response (AHI using videoendoscopy, we performed upper <50% of pre-LAUP value); 15 (34%) had a airway imaging in a subgroup of patients to poor response (AHI >50% of pre-LAUP explore possible mechanisms of action of value); and 13 (30%) patients were worse LAUP. We wished to determine whether post- (AHI >100% of pre-LAUP value). The operative changes in velopharyngeal dimen- velopharyngeal cross sectional area and sions are related to treatment response. anteroposterior diameter increased fol- lowing LAUP (p<0.05). Quality of life indices improved significantly in all do- Methods on October 1, 2021 by guest. Protected copyright. mains and sleepiness decreased. The SUBJECTS Forty four patients were recruited through the snoring index did not decrease signifi- Sleep Disorders Program at Vancouver Hospi- Division of cantly. No preoperative anthropometric or tal and Health Sciences Centre. Once the diag- Respiratory Medicine, videoendoscopic measures were predic- nosis of OSA was confirmed by overnight Department of tive of a good response to LAUP. Patients Medicine, University polysomnography, each patient was counselled who were worse after LAUP had milder of British Columbia, about the full range of treatment options avail- baseline apnoea severity than those in the Vancouver, British able for OSA. Patients with symptomatic OSA Columbia, Canada other response groups. (apnoea hypopnoea index (AHI) >10/h), CFRyan Conclusions—The treatment response to LLLove regardless of severity, were eligible for recruit- LAUP is variable and unpredictable, and ment. Patients with severe OSA (AHI >30/h) only a few patients achieve a satisfactory Correspondence to: were strongly encouraged to pursue nasal con- Dr C F Ryan, Division of response. There appears to be no relation- tinuous positive airway pressure (CPAP) Respiratory Medicine, ship between subjective and objective therapy because of its proven safety and Vancouver General Hospital, measures of treatment eYcacy. 2775 Heather Street, eYcacy. Patients were advised that LAUP was ( 2000;55:399–404) Vancouver, British Thorax still considered to be an experimental treat- Columbia, V5Z 3J5 Canada email: Keywords: obstructive sleep apnoea; uvulopalatoplasty; ment for sleep disordered breathing. Only [email protected] laser assisted uvulopalatoplasty those patients who elected to pursue LAUP as initial treatment were eligible for recruitment. Received 22 November 1999 Returned to authors Before recruitment each eligible patient under- 12 January 2000 Laser assisted uvulopalatoplasty (LAUP) is a went a careful evaluation by an otolaryngolo- Revised version received new surgical procedure which was initially gist. Once suitability for the surgical procedure 8 February 2000 1 Accepted for publication introduced for the treatment of snoring. was confirmed, patients were entered consecu- 8 February 2000 Despite a lack of objective evidence to support tively into the study. Each patient gave written 400 Ryan, Love informed consent and the study protocol was (Olympus LF2; Olympus Corporation, Lake approved by our institutional ethics review Sweeny, New York, USA, outer diameter committees. 3.8 mm) and an oesophageal pressure trans- Thorax: first published as 10.1136/thorax.55.5.399 on 1 May 2000. Downloaded from ducer (Model MPC-55; Millar Instruments STUDY DESIGN Inc, Houston, Texas, USA; outer diameter Each patient had an overnight polysomnogram 1.7 mm) were passed through the nose into the performed before enrollment in the study and pharynx. The pressure transducer was posi- again at least three months after surgery. A tioned in the oesophagus approximately 10 cm subgroup of 16 consecutive patients who gave above the diaphragm. Oesophageal pressures additional consent completed quality of life were amplified (Millar), displayed on a compu- and sleepiness questionnaires and underwent ter monitor, and recorded on a computer ambulatory measurements of snoring noise. Of (Direc Physiological Recording System; this group, 11 also underwent upper airway Raytech Instruments, Vancouver, BC) for sub- videoendoscopy. All measurements were re- sequent analysis. A medical TV camera (Olym- peated at least three months after the opera- pus OTV2) attached to the endoscope gener- tion. ated images of the upper airway lumen which were recorded continuously and time coded on POLYSOMNOGRAPHY videotape (Video Cassette Recorder Model Sleep and its various stages were documented VO9850; Sony Corporation, Japan) for later by standard electroencephalographic (EEG), analysis. Images were obtained in the velophar- electro-oculographic (EOG), and electromyo- ynx at the free margin of the soft palate before graphic (EMG) criteria.16 EEG was recorded and after LAUP. with electrodes applied at C3-A2 and C4-A1 (according to the International 10-20 system) IMAGE ANALYSIS and EMG activity was recorded from the sub- The analysis of the videoendoscopic images mental muscles and anterior tibialis muscles. was performed by one investigator (LLL), Apnoeas were defined as cessation of airflow at blinded to the polysomnographic data, and the nose and mouth for longer than 10 s and using the technique which we have described 17 were documented by an infrared CO2 analyser previously. The velopharyngeal cross sec- (Model 1260; Novamatrix Medical Systems tional area, anteroposterior and lateral diam- Inc, Wallingford, Connecticut, USA) which eters were measured from the stored images records from both the nose and mouth. using a high resolution frame grabber (Model Hypopnoeas were defined as reductions of DT3851; Data Translation, Marlboro, Massa- >50% in the excursion of the sum channel of a chusetts, USA) and image processing software respiratory inductance plethysmograph (Respi- (Global Lab Image; Data Translation). Signals trace; Ambulatory Monitoring Equipment, from the time code generator and oesophageal Ardsley, New York,USA) measuring chest wall pressure transducer were stored on-line in a http://thorax.bmj.com/ and abdominal movement. A single electro- computer (80486; ANO Automation, Vancou- cardiographic (ECG) lead (modified V2)was ver, BC), enabling selection of images based on monitored to detect cardiac arrhythmias. Arte- simultaneous pressure measurements. Meas- rial oxygen saturation (SaO2) was monitored urements were made at end tidal expiration, as continuously with a pulse oximeter (Model determined by the oesophageal pressure trans- N-100; Nellcor Inc, Hayward, California, ducer, and during a Muller manoeuvre. The USA) attached to the index finger. The data airway lumen was traced freehand to generate a were recorded on a 15-channel polygraph region of interest that was quantified based on (Model 78; Grass Instruments Co, Quincy, the number of enclosed pixels. The border on October 1, 2021 by guest. Protected copyright. Massachusetts, USA) and fed into the CNS between the airway and soft tissues was deter- Sleep Lab System (Model 200; CNS Inc, mined visually. All measurements were made Chanhassen, Minnesota, USA). The complete using the diameter of the intraluminal catheter record was manually scored for sleep stage and as a linear calibration. apnoea type and duration. Severity of sleep apnoea was assessed in terms of number of QUALITY OF LIFE apnoeas and number of
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