低觉醒阈值与舌下神经刺激的长期依从性

文献信息

中文摘要

重要性： 低觉醒阈值（ArTH）是阻塞性睡眠呼吸暂停（OSA）中常见的病理生理内型，与睡眠质量差和持续气道正压治疗依从性降低相关。其对舌下神经刺激（HGNS）依从性的影响尚不清楚。
目的： 评估基线ArTH与HGNS依从性及结局之间的关联。
设计、场所和参与者： 这项回顾性队列研究在2个学术医学中心（匹兹堡大学医学中心和托马斯·杰斐逊大学医院）进行。参与者包括2021年1月至2023年12月期间接受HGNS植入的成人，其术前睡眠研究数据足以计算ArTH，并且在3个月和6个月随访时有客观设备依从性数据。
暴露： 术前ArTH状态（低 vs 高），使用基于常规睡眠研究数据中的呼吸暂停-低通气指数（AHI）、氧饱和度最低值和低通气比例的经过验证的复合评分算法进行估计。
主要结局和测量指标： 主要结局是激活后3个月和6个月时的分类HGNS依从性（90天期间超过70%的夜晚每晚使用≥4小时）。次要结局包括连续依从性指标（小时/晚、使用夜晚百分比、每晚使用≥4小时的夜晚百分比、每晚暂停次数）以及时间点之间的纵向依从性转变模式。
结果： 在160例纳入患者中（中位[IQR]年龄，66.1[58.9-72.1]岁；105例[66%]男性），65例（41%）为低ArTH，95例（59%）为高ArTH。与低ArTH患者相比，高ArTH患者的基线AHI更高（中位[IQR]，39.0[30.7-47.1]事件/小时 vs 20.8[17.3-25.8]事件/小时），并且HGNS后AHI的相对降低幅度更大（中位[IQR]，-53.7%[-67.8%至-6.4%] vs -33.8%[-67.8%至-5.4%]）。低ArTH与从3个月时依从转变为6个月时不依从相关（65例患者中的17例[26%] vs 95例患者中的5例[5.3%]；比值比，12.60；95% CI，3.70-56.10）。平均每晚使用时长和每晚暂停次数在组间无显著差异。
结论和意义： 这项队列研究表明，低ArTH与HGNS治疗的逐渐脱离相关，其特征是错过治疗夜晚而非每晚使用不耐受。将ArTH内型分析纳入术前评估可能识别出有治疗脱离风险的患者，从而实现个性化咨询和指导策略，以改善HGNS依从性和患者结局。

英文摘要

IMPORTANCE: A low arousal threshold (ArTH) is a common pathophysiologic endotype in obstructive sleep apnea (OSA) and has been associated with poor sleep quality and reduced adherence to positive airway pressure therapy. Its impact on adherence to hypoglossal nerve stimulation (HGNS) is unclear.
OBJECTIVE: To evaluate the association between baseline ArTH and HGNS adherence and outcomes.
DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study took place at 2 academic medical centers (University of Pittsburgh Medical Center and Thomas Jefferson University Hospital). Participants included adults who underwent HGNS implantation between January 2021 and December 2023, with preoperative sleep study data sufficient to calculate ArTH and objective device adherence data available at the 3- and 6-month follow-up.
EXPOSURE: Preoperative ArTH status (low vs high), estimated using a validated composite scoring algorithm based on apnea-hypopnea index (AHI), oxygen desaturation nadir, and hypopnea proportion from routine sleep study data.
MAIN OUTCOMES AND MEASURES: The primary outcome was categorical HGNS adherence (≥4 h/night on >70% of nights over a 90-day period) at 3 and 6 months postactivation. Secondary outcomes included continuous adherence metrics (h/night, percentage of nights used, percentage of nights with ≥4 hours of use, pauses per night) and longitudinal adherence transition patterns between time points.
RESULTS: Among 160 included patients (median [IQR] age, 66.1 [58.9-72.1] years; 105 [66%] male), 65 (41%) had low ArTH and 95 (59%) had high ArTH. Patients with high ArTH, compared with those with low ArTH, had higher baseline AHI (median [IQR], 39.0 [30.7-47.1] events/h vs 20.8 [17.3-25.8] events/h) and greater relative reduction in AHI after HGNS (median [IQR], -53.7% [-67.8% to -6.4%] vs -33.8% [-67.8% to -5.4%]). Low ArTH was associated with transition from adherence at 3 months to nonadherence at 6 months (17 of 65 patients [26%] vs 5 of 95 patients [5.3%]; odds ratio, 12.60; 95% CI, 3.70-56.10). Average nightly use duration and pauses/night did not differ meaningfully between groups.
CONCLUSIONS AND RELEVANCE: This cohort study demonstrates that low ArTH is associated with progressive disengagement from HGNS therapy, characterized by missed nights of therapy rather than nightly use intolerance. Incorporating ArTH endotyping into preoperative evaluation may identify patients at risk for therapy disengagement, enabling personalized counseling and guided strategies to improve HGNS adherence and patient outcomes.