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Efeitos da Pressão Positiva Contínua nas Vias Aéreas Versus Dispositivos de Avanço Mandibular na Síndrome da Apneia Obstrutiva do Sono: Revisão Sistemática
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Abstract(s)
Introdução: A Síndrome da Apneia Obstrutiva do Sono é um distúrbio respiratório crónico, caracterizado por colapsos recorrentes das vias aéreas superiores durante o sono, originando uma obstrução no fluxo de ar e, portanto, uma diminuição dos níveis de saturação de oxigénio. Como consequência, a hipóxia, a pressão torácica negativa e os despertares noturnos frequentes, podem levar a um aumento da pressão arterial e da frequência cardíaca, contribuindo para um maior risco de hipertensão, arritmias ou outras doenças cardiovasculares. Além disso, a Síndrome da Apneia Obstrutiva do Sono tem uma forte associação com doenças metabólicas, sendo que uma grande parte dos doentes acabam por preencher os critérios da síndrome metabólica. Por isso, existe a necessidade de oferecer múltiplas modalidades de tratamento, a fim de modificar o seu perfil de risco cardiovascular e metabólico, que neste momento incluem além da Pressão Positiva Contínua nas Vias aéreas, as estratégias de perda de peso e de programas para aumentar a atividade física e os aparelhos orais. Assim, o principal objetivo desta revisão sistemática é perceber e comparar os efeitos que a Pressão Positiva Contínua nas Vias aéreas e os Dispositivos de Avanço Mandibular têm em doentes com esta patologia e avaliar a possibilidade de usar aparelhos orais mesmo em casos mais graves. Metodologia: Procedeu-se à pesquisa bibliográfica de ensaios clínicos randomizados cruzados e de ensaios clínicos randomizados controlados, que comparem os efeitos da Pressão Positiva Contínua nas Vias aéreas e dos Dispositivos de Avanço Mandibular, em pessoas maiores de 18 anos, com diagnóstico de Síndrome da Apneia Obstrutiva do Sono, através da base de dados PubMed. Foram utilizadas as seguintes palavras-chave: “Continuous Positive Airway Pressure” AND “Mandibular Advancement Device” AND “Obstructive Sleep Apnea”. A Avaliação de risco de viés foi feita de acordo com o “Revised Cochrane risk-of-bias tool for randomized trials (RoB 2)”. Resultados: Foram obtidos inicialmente 253 resultados, no entanto apenas 17 estudos foram incluídos nesta revisão sistemática, tendo praticamente todos os estudos um risco de viés “pouco claro”, à exceção de dois estudos, onde o risco de viés é “alto”. Os outcomes dos artigos selecionados incluem os resultados polissonográficos, outcomes funcionais e qualidade de vida, outcomes cardiovasculares e metabólicos, efeitos adversos, adesão, preferência e satisfação, custo-efetividade e custo-utilidade. Discussão: Os parâmetros polissonográficos melhoram mais significativamente com a Pressão Positiva Contínua nas Vias aéreas comparativamente com o Dispositivo de Avanço Mandibular. No entanto, apesar da Pressão Positiva Contínua nas Vias aéreas ser mais eficaz na atenuação da Síndrome da Apneia Obstrutiva do Sono e também mais custo-efetiva, o Dispositivo de Avanço Mandibular tem na generalidade maior adesão, o que permite restaurar um sono satisfatório, levando consequentemente à melhoria dos sintomas subjetivos. No entanto, não existe uma diferença significativa entre os dois tratamentos nos outcomes funcionais e na qualidade de vida. Além disso, apesar de demonstrado o maior impacto nos outcomes metabólicos com a Pressão Positiva Contínua nas Vias aéreas, alguns estudos demonstraram que nenhum dos dois tratamentos apresentou melhorias significativas nos desfechos cardiovasculares. Conclusão: Os resultados obtidos nesta revisão sistemática vão ao encontro daquilo que é a prática atual, ou seja, o uso do Pressão Positiva Contínua nas Vias aéreas como gold-standard para os casos moderados a graves de Apneia Obstrutiva do Sono e também como uma boa opção para a apneia leve do sono. Já os aparelhos orais são uma opção eficaz para casos de gravidade leve a moderada, que preferem este tratamento à Pressão Positiva Contínua nas Vias aéreas ou que não a conseguem tolerar.
Introduction: The Obstructive Sleep Apnea Syndrome is a chronic respiratory disorder characterized by recurrent collapses of the upper airways during sleep, causing airflow obstruction and, consequently, a reduction in oxygen saturation levels. As a result, hypoxia, negative thoracic pressure and frequent nocturnal awakenings can increase blood pressure and heart rate, contributing to a higher risk of hypertension, arrhythmias, or other cardiovascular diseases. Additionally, the Obstructive Sleep Apnea Syndrome is strongly associated with metabolic disorders, with a significant proportion of patients with metabolic syndrome. Therefore, it is necessary to offer multiple treatment modalities to modify the cardiovascular and metabolic risk profile, which currently include Continuous Positive Airway Pressure, weight loss strategies, physical activity programs and oral appliances. Thus, the main objective of this systematic review is to understand and compare the effects of the Continuous Positive Airway Pressure and Mandibular Advancement Devices in patients with this pathology and to evaluate the possibility of using oral appliances even in more severe cases. Methodology: A bibliographic search of randomized crossover trials and randomized controlled trials was conducted to compare the effects of the Continuous Positive Airway Pressure and Mandibular Advancement Devices, in individuals over 18 years old diagnosed with Obstructive Sleep Apnea, using PubMed database. The Keywords used were Continuous Positive Airway Pressure” AND “Mandibular Advancement Device” AND “Obstructive Sleep Apnea”. The risk of bias assessment was performed according to the “Revised Cochrane risk-of-bias tool for randomized trials (RoB 2).” Results: Initially, 253 results were obtained, but only 17 studies were included in this systematic review, with almost all studies presenting an “unclear” risk of bias, except for two studies where the risk of bias was “high.” The outcomes of the selected articles include polysomnographic results, functional results and quality of life, cardiovascular and metabolic results, adverse effects, adherence, preference and satisfaction, costeffectiveness and cost-utility. Discussion: Polysomnographic parameters improve more significantly with the Continuous Positive Airway Pressure compared to Mandibular Advancement Devices. However, while the Continuous Positive Airway Pressure is more effective in reducing respiratory events and is also more cost-effective, the Mandibular Advancement Devices generally have higher adherence rates, which contributes to the restoration of satisfactory sleep and, consequently, the improvement in subjective symptoms. However, there is no significant difference between the two treatments in functional outcomes and quality of life. Additionally, although the Continuous Positive Airway Pressure shows a greater impact on metabolic outcomes, some studies demonstrate that neither treatment achieved significant improvements in cardiovascular outcomes. Conclusion: The findings of this systematic review are aligned with the current clinical practice, which advocates the use of the Continuous Positive Airway Pressure as the goldstandard for moderate to severe cases of Obstructive Sleep Apnea Syndrome and as a viable option for mild sleep apnea. Oral appliances, on the other hand, are an effective option for mild to moderate cases, especially for patients who prefer this treatment or are unable to tolerate the Continuous Positive Airway Pressure.
Introduction: The Obstructive Sleep Apnea Syndrome is a chronic respiratory disorder characterized by recurrent collapses of the upper airways during sleep, causing airflow obstruction and, consequently, a reduction in oxygen saturation levels. As a result, hypoxia, negative thoracic pressure and frequent nocturnal awakenings can increase blood pressure and heart rate, contributing to a higher risk of hypertension, arrhythmias, or other cardiovascular diseases. Additionally, the Obstructive Sleep Apnea Syndrome is strongly associated with metabolic disorders, with a significant proportion of patients with metabolic syndrome. Therefore, it is necessary to offer multiple treatment modalities to modify the cardiovascular and metabolic risk profile, which currently include Continuous Positive Airway Pressure, weight loss strategies, physical activity programs and oral appliances. Thus, the main objective of this systematic review is to understand and compare the effects of the Continuous Positive Airway Pressure and Mandibular Advancement Devices in patients with this pathology and to evaluate the possibility of using oral appliances even in more severe cases. Methodology: A bibliographic search of randomized crossover trials and randomized controlled trials was conducted to compare the effects of the Continuous Positive Airway Pressure and Mandibular Advancement Devices, in individuals over 18 years old diagnosed with Obstructive Sleep Apnea, using PubMed database. The Keywords used were Continuous Positive Airway Pressure” AND “Mandibular Advancement Device” AND “Obstructive Sleep Apnea”. The risk of bias assessment was performed according to the “Revised Cochrane risk-of-bias tool for randomized trials (RoB 2).” Results: Initially, 253 results were obtained, but only 17 studies were included in this systematic review, with almost all studies presenting an “unclear” risk of bias, except for two studies where the risk of bias was “high.” The outcomes of the selected articles include polysomnographic results, functional results and quality of life, cardiovascular and metabolic results, adverse effects, adherence, preference and satisfaction, costeffectiveness and cost-utility. Discussion: Polysomnographic parameters improve more significantly with the Continuous Positive Airway Pressure compared to Mandibular Advancement Devices. However, while the Continuous Positive Airway Pressure is more effective in reducing respiratory events and is also more cost-effective, the Mandibular Advancement Devices generally have higher adherence rates, which contributes to the restoration of satisfactory sleep and, consequently, the improvement in subjective symptoms. However, there is no significant difference between the two treatments in functional outcomes and quality of life. Additionally, although the Continuous Positive Airway Pressure shows a greater impact on metabolic outcomes, some studies demonstrate that neither treatment achieved significant improvements in cardiovascular outcomes. Conclusion: The findings of this systematic review are aligned with the current clinical practice, which advocates the use of the Continuous Positive Airway Pressure as the goldstandard for moderate to severe cases of Obstructive Sleep Apnea Syndrome and as a viable option for mild sleep apnea. Oral appliances, on the other hand, are an effective option for mild to moderate cases, especially for patients who prefer this treatment or are unable to tolerate the Continuous Positive Airway Pressure.
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Keywords
Dispositivos de Avanço Mandibular Pressão Positiva Contínua nas Vias Aérea Síndrome da Apneia Obstrutiva do Sono Mandibular Advancement Device Continuous Positive Airway Pressure Obstructive Sleep Apnea