摘要
理由：呼吸费力（RE）增加是阻塞性睡眠呼吸暂停（OSA）的一个重要特征。虽然之前的研究已经证实了下颌前突装置（MAD）疗法在降低呼吸暂停-低通气指数（AHI）方面的疗效，但 MAD疗法对RE负担的影响仍有待探索：在这项研究中，我们使用了一种经过验证的下颌骨运动（MJM）监测技术，以确定MAD突出水平与RE负担之间的剂量-反应关系，RE负担是指在MAD滴定过程中呼吸努力升高（REMOV）所花费的总睡眠时间（TST）百分比：这项前瞻性队列研究共纳入 93 名符合 MAD 治疗条件的 OSA 患者。主观滴定过程包括根据 OSA 症状的持续或恶化情况进行反复调整。最佳 AHI 和 REMOV 反应分别定义为 AHI 降低 50%以上和残余 REMOV 低于 14% TST。基于 MJM 的家庭睡眠测试在初始、中间和最终突出水平下进行。通过回归分析估计了治疗对 REMOV 的影响：在三个滴定步骤中，AHI 和 REMOV 分别减少了 TST 的 14.5%、16.8% 和 18.6%。然而，在 REMOV 和 AHI 反应之间观察到了一致的差异：在滴注结束时，68.8% 的患者在两个指标上都达到了最佳反应，而 15.1% 的患者有最佳的 REMOV 反应，但 AHI 没有恢复正常，5.4% 的患者则相反。回归分析表明，REMOV 具有明显的剂量-反应关系，在 0-6.5 毫米的突出范围内，TST 降低 10%，超过 6.5 毫米后，益处逐渐减少。值得注意的是，每向前推进一毫米，REMOV的TST就会提高2.6%（95%CI：-3.0；-2.1）：我们的研究结果表明，MAD 的突出水平与 RE 负担的改善之间存在剂量反应关系。AHI和REMOV的最佳反应标志着MAD疗法在减少阻塞性呼吸事件和RE负担方面具有更高的疗效。这强调了在 MAD 治疗管理中使用家庭 MJM 分析来监测这两个关键指标的益处，以获得更好的临床结果并提高 MAD 滴定的疗效。Rationale: Increased respiratory effort (RE) is a critical feature of obstructive sleep apnea (OSA). While prior studies have established the efficacy of mandibular advancement device (MAD) therapy in reducing the apnea-hypopnea index (AHI), the impact of MAD therapy on RE burden remains unexplored.
Objective: In this study, we used a validated mandibular jaw movement (MJM) monitoring technology to determine the dose-response relationship between MAD protrusion levels and RE burden measured as the percentage of total sleep time (TST) spent in elevated respiratory effort (REMOV) during MAD titration.
Methods: Ninety-three OSA patients eligible for MAD treatment were included in this prospective cohort study. A subjective titration process involved iterative adjustments based on the persistence or worsening of OSA symptoms. Optimal AHI and REMOV responses were defined as an AHI reduction of greater than 50% and a residual REMOV lower than 14% TST, respectively. MJM-based home sleep tests were conducted at initial, intermediate, and final protrusion levels. The treatment effect on REMOV was estimated by regression analysis.
Results: AHI and REMOV reductions increased progressively with higher MAD protrusion levels, with AHI decreasing by -10.3, -12.7, and -13.0 events/h and REMOV by 14.5%, 16.8%, and 18.6% of TST across the three titration steps. However, a consistent discrepancy was observed between REMOV and AHI responses: at the end of titration, 68.8% of patients achieved optimal responses for both indices, while 15.1% had optimal REMOV response without AHI normalization, and 5.4% showed the reverse. Regression analysis showed a significant dose-response relationship for REMOV, with a 10% TST reduction within the 0-6.5 mm protrusion range and diminishing benefits beyond 6.5 mm. Of note, each millimeter advancement would yield a 2.6% TST (95%CI: -3.0; -2.1) improvement in REMOV.
Conclusion: Our findings demonstrate a dose-response relationship between the MAD protrusion level and the improvement in RE burden. Optimal responses in both AHI and REMOV signify greater efficacy of MAD therapy in reducing obstructive respiratory events and RE burden. This underscores the benefit of using at-home MJM analysis to monitor these two critical metrics in the management of MAD therapy to achieve better clinical outcomes and enhance MAD titration efficacy.
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