Edward M. Weaver, MD, MPH. University of Washington VA Puget Sound

Transcription

1 What is the Role of Soft Palate Surgery in OSA? Edward M. Weaver, MD, MPH University of Washington Harborview Medical Center VA Puget Sound

2 Question: Should we do UPPP?

3 Answer: Yes

4 Role of Palate Surgery Treat palatal l obstruction ti When CPAP not successful With realistic expectations

5 Should We Do UPPP? 1. The case against UPPP 2. The case for UPPP 3. A synthesis

6 Why We Should Not Do UPPP UPPP rarely cures OSA

7 Elshaug, Sleep 2007; 30:461-7

8 Elshaug, Sleep 2007; 30:461-7

9 Surgery Rarely Cures OSA Figure 1 Level 4 Elshaug, Sleep 2007; 30:461-7

10 Implication Surgery should not be offered to treat sleep apnea. surgery should be restricted to controlled clinical trials

11 Why We Should Not Do UPPP UPPP rarely cures OSA

12 TRUE! But

13 But No treatment t t consistently tl cures OSA Surgery usually helps

14 Pittman, Sleep & Breath 2006;10:123-31

15 CPAP Success Success: AHI CPAP Efficacy 5 27% 10 61% 15 81% 20 87% Table 2 Level 4 Pittman, Sleep & Breath 2006;10:123-31

16 Surgery Helps OSA Figure 1 Level 4 Elshaug, Sleep 2007;30:461-7

17 Appropriate Goals of Salvage Surgery If UPPP is PRIMARY therapy: CURE is an appropriate goal If UPPP is SALVAGE therapy: IMPROVEMENT is an appropriate goal

18 Appropriate Goals of Salvage Surgery Improve CLINICAL OUTCOMES: Mortality risk Cardiovascular disease risk Motor vehicle accident risk Quality of life

19 UPPP & Death

20 Marti, Eur Resp J 2002;20:

21 OSA Survival Treated Untreated Figure 1 Level 2 Marti, Eur Resp J 2002;20:

22 OSA Mortality Adjusted* Hazard Ratio of Death None CPAP UPPP P = 0.05 (N=98) (N=124) (N=88) *Adjusted for age, sex, smoking, BMI, AHI, AHT, CHD, COPD. Adapted from Table 4 Level 2 Marti, Eur Resp J 2002;20:

23 UPPP & Cardiovascular Dz

24 Peker, AJRCCM 2002;166:159-65

25 UPPP & Cardiovascular Dz CPAP UPPP 64% 50% 36% 50% Figure 2 Level 2 Peker, AJRCCM 2002;166:159-65

26 UPPP & Cardiovascular Dz CPAP+UPPP 32% 68% Figure 2 Level 2 Peker, AJRCCM 2002;166:159-65

27 UPPP & Motor Vehicle Accidents

28 Haraldsson, Laryngoscope 1995;105:657-61

29 UPPP & Accidents Accident Type Relative Risk: OSA/Control Before UPPP After UPPP Single-car Corrected for driving exposure. P< Table V Level 2 Haraldsson, Laryngoscope 1995;105:657-61

30 UPPP & Quality of Life

31 FOSQ Score * * *p<0.001p mos 3 mos 6 mos Time from UPPP Level 4 Weaver, OtoHNS 2007;137:P67

32 Which h Is Better? Untreated Sleep Apnea Partially Treated Sleep Apnea

33 Which h Is Better? Untreated Sleep Apnea Partially Treated Sleep Apnea

34 Why We Should Not Do UPPP UPPP rarely cures OSA

35 Why We Should Do UPPP No treatment t t cures OSA Surgery often last-lineline therapy CPAP unsuccessful OSA untreated t Improvement w/o cure is still a benefit

36 Why We Should Do UPPP Significant benefits to: Physiology Mortality risk Cardiovascular dz risk Motor vehicle accident risk Quality of life

37 Realistic Expectations Improved clinical outcome NOT cure Difficult acute recovery Complications

38 Complications Pain Bleeding Velopharyngeal Incompetence Dysphagia Stenosis Voice change Failure Life-threatening complications

39 Why We Should Not Do UPPP UPPP risks too much harm

40 Franklin, Sleep 2009; 32:27-36

41 Franklin, Sleep 2009; 32:27-36

42 Level 4 Franklin, Sleep 2009; 32:27-36

43 Level 4 Franklin, Sleep 2009; 32:27-36

44 Why We Should Not Do UPPP UPPP risks too much harm

45 FALSE!

46 Benefits Outweigh Harms When compared head-to-head Swallowing difficulty Quality of life Mortality risk

47 Swallowing Difficulty Relatively l few of these patients t regretted UPPP Swallowing difficulty often temporary Patients adapted or not bothered Benefits outweighed harm Patients informed

48 Level 4 Franklin, Sleep 2009; 32:27-36

49 Side Effects After Surgical Treatment of Snoring Survey 415 patients after snoring surgery 62% had side effect: globus (40%), regurgitation, taste, smell, voice. Significant ifi improvement over time Level 4 Hagert, J ORL 2000; 22:76-80

50 LAUP Most complaints minor 14% dissatisfied Level 4 Gronstved, Acta Oto 2000; S543:190-2

51 Level 4 Gronstved, Acta Oto 2000; S543:190-2

52 UPPP or LAUP Most complaints minor Half of swallowing disturbances resolved 12% regretted surgery Level 4 Lysdahl, Acta Oto 2002; 122:752-7

53 Level 4 Lysdahl, Acta Oto 2002; 122:752-7

54 UPPP or UPP 29% w/o pre-op dysphagia developed dysphagia 0% regretted surgery Level 4 Jaghagen, Acta Oto 2004; 124:

55 Level 4 Jaghagen, Acta Oto 2004; 124:

56 UPPP 3 mos: 5% w/ taste loss 9 mos: 1% w/ taste loss Significant improvement over time Level 2 Li, OtoHNS 2006; 134:985-90

57 Quality of Life Two studies Both showed net improvement

58 FOSQ Score * * *p<0.001p mos 3 mos 6 mos Time from UPPP Level 4 Weaver, OtoHNS 2007;137:P67

59 Walker-Engstrom, J Sleep Res 2000;9:303-8

60 Minor Symptoms Evaluation Profile Level 4 Walker-Engstrom, J Sleep Res 2000;9:303-8

61 Mortality Risk Overall survival improved Low 30-day mortality risk (low risk of harm) Improved long-term benefit (large benefit) Immediate net benefit

62 30-d Mortality Rate: 7/3130 = 0.2% (95% CI 0.1%, 0.4%) Level 2 Kezirian, Laryngoscope 2004; 114:450-3

63 Weaver, Sleep 2004;27:A208

64 Surgery Survival Kaplan-Meier survival estimates, by therapy UPPP = 3,977 CPAP = 28,612 No Tx = 116,678 UPPP CPAP No Tx analysis time Level 2 Weaver, Sleep 2004;27:A208

65 Surgery Survival UPPP CPAP No Tx 1 month Level 2 Weaver, Sleep 2004;27:A208

66 Which Is Worse? Risk of Surgery Risk of Untreated Sleep Apnea

67 Which Is Worse? Risk of Surgery Risk of Untreated Sleep Apnea

68 Why We Should Not Do UPPP UPPP risks too much harm

69 Why We Should Do UPPP Benefits outweigh harms: Symptoms Quality of life Mortality risk

70 Role of Palate Surgery Treat palatal l obstruction ti When CPAP not successful With realistic expectations Benefits Potential harms

71 What is the Role of Soft Palate Surgery for OSA? REFERENCES CITED IN SYLLABUS 1. Elshaug AG, Moss JR, Southcott AM, Hiller JE. Redefining success in airway surgery for obstructive sleep apnea: a meta analysis and synthesis of the evidence. Sleep 2007;30(4): Elshaug AG, Moss JR, Hiller JE, Maddern GJ. Upper airway surgery should not be first line treatment for obstructive sleep apnoea in adults. BMJ 2008;336(7634): Author reply to Sam Robinson. BMJ, (Accessed January 25, 2010, at 4. Pittman SD, Pillar G, Berry RB, Malhotra A, MacDonald MM, White DP. Follow-up assessment of CPAP efficacy in patients with obstructive sleep apnea using an ambulatory device based on peripheral arterial tonometry. Sleep Breath 2006;10(3): Marti S, Sampol G, Munoz X, et al. Mortality in severe sleep apnoea/hypopnoea syndrome patients: impact of treatment. Eur Respir J 2002;20(6): Peker Y, Hedner J, Norum J, Kraiczi H, Carlson J. Increased incidence of cardiovascular disease in middle-aged men with obstructive sleep apnea: a 7-year follow-up. Am J Respir Crit Care Med 2002;166(2): Haraldsson PO, Carenfelt C, Lysdahl M, Tingvall C. Does uvulopalatopharyngoplasty inhibit automobile accidents? Laryngoscope 1995;105(6): Weaver EM, Woodson BT, Witsell DL, et al. UPPP and subjective sleep apnea outcomes: The SLEEP Study. Otolaryngology - Head & Neck Surgery 2007;137(2):P67 (abstract). 9. Franklin KA, Anttila H, Axelsson S, et al. Effects and side-effects of surgery for snoring and obstructive sleep apnea A systematic review. Sleep 2009;32(1): Hagert B, Wikblad K, Odkvist L, Wahren LK. Side effects after surgical treatment of snoring. ORL J Otorhinolaryngol Relat Spec 2000;62(2): Grontved AM, Karup P. Complaints and satisfaction after uvulopalatopharyngoplasty. Acta Otolaryngol Suppl 2000;543: Lysdahl M, Haraldsson PO. Uvulopalatopharyngoplasty versus laser uvulopalatoplasty: prospective long-term follow-up of self-reported symptoms. Acta Otolaryngol 2002;122(7): Jaghagen EL, Berggren D, Dahlqvist A, Isberg A. Prediction and risk of dysphagia after uvulopalatopharyngoplasty and uvulopalatoplasty. Acta Otolaryngol 2004;124(10):

72 14. Li HY, Lee LA, Wang PC, et al. Taste disturbance after uvulopalatopharyngoplasty for obstructive sleep apnea. Otolaryngol Head Neck Surg 2006;134(6): Walker-Engstrom ML, Wilhelmsson B, Tegelberg A, Dimenas E, Ringqvist I. Quality of life assessment of treatment with dental appliance or UPPP in patients with mild to moderate obstructive sleep apnoea. A prospective randomized 1-year follow-up study. J Sleep Res 2000;9(3): Kezirian EJ, Weaver EM, Yueh B, et al. Incidence of Serious Complications After Uvulopalatopharyngoplasty. Laryngoscope 2004;114: Weaver EM, Maynard C, Yueh B. Mortality of veterans with sleep apnea: untreated versus treated. Sleep 2004;27:A208 (Abstract). ADDITIONAL SUPPORTING REFERENCES NOT CITED IN SYLLABUS 18. Sher AE, Schechtman KB, Piccirillo JF. The efficacy of surgical modifications of the upper airway in adults with obstructive sleep apnea syndrome. Sleep 1996;19(2): Weaver EM, Maynard C, Yueh B. Survival of veterans with sleep apnea: continuous positive airway pressure versus surgery. Otolaryngol Head Neck Surg 2004;130(6): Keenan SP, Burt H, Ryan CF, Fleetham JA. Long-term survival of patients with obstructive sleep apnea treated by uvulopalatopharyngoplasty or nasal CPAP. Chest 1994;105(1): Peker Y, Carlson J, Hedner J. Increased incidence of coronary artery disease in sleep apnoea: a long-term follow-up. Eur Respir J 2006;28(3): Change? BMJ, (Accessed January 25, 2010, at Sleep surgery survival study--clarifications. BMJ, (Accessed January 25, 2010, at Sleep surgery cardiovascular outcomes study--clarifications. BMJ, (Accessed January 25, 2010, at Therapeutic nihilism. BMJ, (Accessed January 25, 2010, at