Case Studies

Canada Sleep Study written by Dr. Rich Balys

Akita Y, Kawakatsu K, Hattori C, Hattori H, Suzuki K, Nishimura T. (2003) Posture of patients with sleep apnea during sleep. Acta Otolaryngol Suppl. 550, 41-5. The effect of posture on sleep apnea syndrome was investigated in a group of subjects which included obese patients. The lateral position was markedly improved in those patients with lower to moderate AHI values. It was also determined that the effect of lateral position sleep diminished as the BMI (Body Mass Index) numbers increased. It is to be noted that this was not a randomized controlled trial.

Bignold, J.J, Deans-Costi, G., Goldsworthy, M.R., Robertson, C.A., McEvoy, D., Catcheside, P.G. & Mercer, J.D. (2009). Poor Long-Term Patient Compliance with the Tennis Ball Technique for Treating Positional Obstructive Sleep Apnea. Journal of clinical sleep medicine 05(05), 428-430 The tennis ball technique (TBT) is one of the original simple methods of positional therapy for positional OSA patients. The results of a questionnaire sent to patients who were prescribed the TBT showed that 80.6 % were not using the TBT anymore nor had they learned to avoid sleeping supine while using the TBT. Their reason for discontinuing is that it is uncomfortable. Only 10% was still using TBT 30 months after prescription.

Cartwright, R.D. (1984) Effect of sleep position on sleep apnea severity. Sleep. 7(2):110-4. Cartwright (1984) evaluated 30 male subjects and compared AHI in supine and in lateral position. The results showed that the AHI fell to half in 80% of the subjects with an inverse relationship to obesity. For 16.5 % the AHI fell to normal limits while in lateral position. Sleep position adjustment can thus be a viable option to treat non obese sleep apnea patients.

George C.F., Millar T.W. & Kryger M.H. (1988) Sleep apnea and body position during sleep. Sleep 11(1):90-9. Apnea frequency (AHI) and apnea duration (AD) were evaluated in all spontaneous body positions during REM and non REM stages, in obese patients. Although the AHI was greater on back than on the side during non REM sleep. During the REM sleep stage the AHI was reduced but still clinically high and AD was longer than in the non REM stage. It was concluded that favoring the lateral side may not be very beneficial for the very obese but is likely to have more benefit for the less obese patients.

Jokic, R., Klimaszewski, A., Crossley, M., Sridhar, G. & Fitzpatrick, M.F. (1999). Positional treatment vs continuous positive airway pressure in patients with positional obstructive sleep apnea. Chest. 115(3), 771-81. Jokic, et al. (1999) compared the effectiveness of CPAP and positional therapy in the management of positional obstructive sleep apnea (OSA). They found in their prospective randomized single blind crossover comparison that the positional treatment was very effective in reducing the time slept supine. Even though the AHI was lower and the mean oxygen saturation was higher on CPAP there was no significant difference in the results of the different sleepiness, wakefulness and quality of life measurements that were taken.

Kushida, C. A., Sherrill S.C.H., Palombini, L., Hyde, P. & Dement, W.C. (2001) Cervical positioning for reduction of sleep disordered breathing in mild to moderate OSAS Sleep Breath 5(2), 71-8. DOI 10.1007/s11325-001-0071-z This study evaluated the effect of a custom fitted cervical pillow on AHI in mild to moderate sleep apnea. They found a trend towards improvement in their AHI despite spending more time supine. A non significant trend towards improvement in subjective sleep efficiency and depth was also found. Kushida, et al. concluded that this custom fitted cervical pillow can be a simple, non invasive treatment for patients with mild to moderate sleep OSA.

Marshall, N.S., Barnes, M., Travier, N., Campbell, A.J., Pierce, R.J., McEvoy, R.D., Neill, A.M., & Gander, P.H. (2006). Continuous positive airway pressure reduces daytime sleepiness in mild to moderate obstructive sleep apnea: a meta-analysis. Severe sleep apnea, with an AHI greater than 30/hour, is effectively treated with CPAP. It is unclear though whether CPAP improves sleepiness in mild to moderate sleep apnea. This Meta analysis analyzed seven randomized controlled trials were CPAP treatment was compared with a placebo or conservative management for the treatment of mild to moderate sleep apnea. Marshall, et al., (2006) concluded that the improvements in subjective sleepiness and objective wakefulness, using CPAP versus placebo or conservative treatment were small.

Oksenberg, A., Silverberg, D.S., Arons, E., & Radwan, H. (1999). The Sleep Supine Position Has a Major Effect on Optimal Nasal Continuous Positive Airway Pressure: Relationship With Rapid Eye Movements and Non-Rapid Eye Movements Sleep, Body Mass Index, Respiratory Disturbance Index, and Age Chest 116, 1000-1006. DOI 10.1378/chest.116.4.1000 This retrospective analysis evaluated the impact of the sleep position on the optimal nasal CPAP pressure. The results show that for most patients who suffer from obstructional sleep apnea, the optimal pressure is significantly higher in the supine position than in the lateral position. This has proven to be true for patients with different degrees of OSA, obese and non obese and young and old.

Skinner, M.A., Kingshott, R.N., Jones,D.R., Homan, S., & Taylor, D.R. (2004) Elevated posture for the management of obstructive sleep apnea. Sleep Breath 8(4), 193-200. This randomized cross over investigation compared the effectiveness of a shoulder / head elevation pillow and nasal CPAP. 50% of the subjects achieved full or partial treatment success with the pillow where 86% achieved full success and 7% achieved partial success with the nasal CPAP treatment. These data show that an elevated posture during sleep is helpful in some individuals and should be considered as second line therapy in the treatment of OSA.

Skinner, M.A., Kingshott, R.N., Filshell, S., & Taylor, R. (2008) Efficacy of the "tennis ball technique" versus n CPAP. A in the management of position dependent obstructive sleep apnoea syndrome This randomized cross over trial compared the efficiency of a thoracic anti supine band (TASB) with nasal CPAP. The band was intended to mimic the tennis ball technique. An AHI of 10 /hour or less was defined as successful treatment. 72.2 % achieved success with the TASB but 89.9 % achieved success with nasal CPAP. TASB though reduced the mean supine sleeping time to about 6% whereas about 35% of sleep time with the nasal CPAP was spent supine.

Zuberi, N.A., Rekab, K. & Nguyen, H.V. (2004) Sleep apnea avoidance pillow effects on obstructive sleep apnea syndrome and snoring Sleep and Breathing 8(4) DOI 10.1007/s11325-004-0201-5 This study determined that an inclined pillow is effective in decreasing the number of events in patients with mild to moderate obstructive sleep apnea. Also it was found that snoring was decreased or eliminated.