Efficacy of the New Generation of Devices for Positional Therapy for Patients With Positional Obstructive Sleep Apnea: A Systematic Review of the Literature and Meta-Analysis

Abstract

Study objectives: In approximately 56% to 75% of patients with obstructive sleep apnea (OSA), the frequency and duration of apneas are influenced by body position. This is referred to as position-dependent OSA or POSA. Patients with POSA can be treated with a small device attached to either the neck or chest. These devices-a new generation of devices for positional therapy (PT)-provide a subtle vibrating stimulus that prevents patients adopting the supine position. The objectives of this study were to determine whether PT is effective in improving sleep study variables and sleepiness, and to assess compliance.

Methods: A systematic review and meta-analysis.

Results: Three prospective cohort studies and four randomized controlled trials were included in this review. Combined data for studies reporting on the effect of PT show that there was a mean difference of 11.3 events/h (54% reduction) in apnea-hypopnea index and 33.6% (84% reduction) in percentage total sleeping time in the supine position. The standardized mean difference for both parameters demonstrated a large magnitude of effect (> 0.8 in both cases).

Conclusions: There is strong evidence that the new generation of devices for PT are effective in reducing the apnea-hypopnea index during short-term follow-up. These devices are simple-to-use for patients and clinicians and are reversible. Under study conditions with short-term follow-up, compliance is high; however, long-term compliance cannot be assessed because of lack of reliable data. Additional long-term, high-quality studies are needed to confirm the role of PT as a single or as a combination treatment modality for OSA patients and to assess long-term compliance.

Keywords: compliance; meta-analysis; obstructive sleep apnea; positional; positional therapy; systematic review.

© 2017 American Academy of Sleep Medicine

Figures

Figure 1. Results of literature search.

PRISMA 2009 flow-diagram. PRISMA = preferred reporting items for systematic reviews and meta-analyses, TBT = tennis ball technique.

Figure 2. Position monitoring and supine alarm device.

Reprinted from Journal of Clinical Sleep Medicine, Vol 7(4), Bignold JJ et al. Accurate position monitoring and improved supine-dependent obstructive sleep apnea with a new position recording and supine avoidance device, pages 376-383, Copyright 2011, with permission of the American Academy of Sleep Medicine.

Figure 3. Sleep position trainer.

Copyright 2017, reprinted with permission of NightBalance B.V.

Figure 4. Neck-worn positional therapy device.

The middle part (ring structure) of the apparatus shown consists of a small vibrating motor (such as the one used in cell phones) and a position sensor. Three small round batteries (two positioned on the left, one on the right) are connected via the white cables. The braided black cables connect the device to the polysomnograph system. Reprinted from Journal of Sleep Research, Vol 21(3), van Maanen JP et al. Evaluation of a new simple treatment for positional sleep apnoea patients, pages 322-329, Copyright 2012, with permission of John Wiley & Sons, Inc.

Figure 5. Neck position training device.

Reprinted from Journal of Clinical Sleep Medicine, Vol 10(8), Levendowski DJ et al. Assessment of a neck-based treatment and monitoring device for positional obstructive sleep apnea, pages 863-871, Copyright 2014, with permission of the American Academy of Sleep Medicine.

Figure 6. Risk of bias summary for the included studies.

Green circle with plus sign = low risk of bias, yellow circle with question mark = unclear risk of bias, red circle with minus sign = high risk of bias.

Figure 7. Forest plot comparing mean apnea-hypopnea index with and without treatment.

Mean, SD, mean difference, and 95% CI values presented as events/h. AHI = apnea-hypopnea index, CI = confidence interval, PT = positional therapy, SD = standard deviation.

Figure 8. Forest plot comparing percentage of total sleep time in the supine position with and without treatment.

CI = confidence interval, PT = positional therapy, SD = standard deviation, TST = total sleep time.