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Pathophysiology of OSA

Four trait seen in patients with OSA

Passive critical closing pressure of the upper airway
(Pcrit)- Collapsibilily
Muscle responsiveness -Compensation
Arousal threshold- airway patency is reduced (apnea,
hypopnea, or high resistance) respiratory drive
increases>>arousal>>sleeping hypopnea and waking
hyperpnea
Loop gain(Ventilatory Control Instability)- hypercapnic
ventilatory response (HCVR). Small disturbances in
ventilation (hypopnea) yield a large response (hyperpnea)
leading to a waxing and waning of ventilation

PALM scale, Eckert, 2014

Dilator muscles of the upper airway play a

critical role in maintaining an open airway
Exercises target on oral cavity and
oropharyngeal structures and other airway
training (singing, didgeridoo, instrument playing)
were developed a method to treat OSA
Myofunctional therapy (MT) first described in
1918.
Guimaraes has proposed MT as a treatment for
OSA since the 1990s

 Myofunctional therapy

Most comprehensive MT exercises are described by

Guimaraes
Involving the soft palate, tongue, and facial muscles and
address stomatognathic functions.

 There have been an increasing number of

studies evaluating the effect of MT

The objective of this study is to

systematically review the literature for

articles evaluating MT as treatment for OSA in
both children and adults

METHODS

Search Strategy
Search on Web of Science, Scopus, MEDLINE,
and The Cochrane Library, update to June 18,
2014.
myofascial reeducation, myofunctional
therapy, obstructive sleep apnea, orofacial
myotherapy, oral myotherapy, oropharyngeal
exercises, sleep, sleep apnea syndromes,
speech therapy, upper airway exercises, and
upper airway remodeling.

Method

Study selection
Oral or oropharyngeal MT as an isolated
treatment for either adult or pediatric OSA
Quantitative polysomnographic, snoring, or
sleepiness data pretreatment and posttreatment
Exclusion criteria
Singing, instrument playing, and studies without
quantitative data
patients lost 10% or more of their body weight
Underwent additional interventions

Pediatric study

Two pediatric studies(25 patients, age 8.43.1y)

Villa et al. prospective randomized
postadenotonsillectomy patients to either
oropharyngeal exercises(N=14) or control
group.
Post-MT AHI was evaluated after 2 month
The AHI M SD reduced from 4.87 3.0/h to
1.84 3.2/h, P = 0.004

Pediatric study

Guilleminault et al. retrospectively reviewed 24

children(s/p adenotonsillectomy, AHI= 0.4 0.3)
11 received MT (intervention group) 13 did not
receive MT (controls).
At the 4-y follow-up, intervention group remained
cured of OSA (AHI 0.5 0.4). Controls
subsequently had a recurrence of OSA (AHI 5.3
1.5/h).

Discussion

MT provides a reduction in AHI of approximately

50% in adults and 62% in children
A clear improvement in lowest oxygen saturation
by approximately 3-4%
MT decreases snoring both subjectively and
objectively.
Subjective sleepiness also improves by a
reduction from 14.8 3.5 to 8.2
4.1(>11=Hypersomnia)

Discussion

Despite the heterogeneity in oral and

oropharyngeal exercises, overall the improvements
in polysomnographic outcomes and sleepiness
were consistent
Future research is needed to help explain the
pathophysiology and mechanism of action of MT
as treatment for OSA(improve muscle tone,
decrease fat content)
Standardized exercises, exploring the effect of
individual exercises

Discussion

Subanalysis for BMI, AHI, age

Based on the current literature. Guimaraes et al.
and Baz et al. had significant reduction in AHI in
overweight (29.6 3.8) and obese patients (BMI
M SD 33.6 2.0).

Effective in children and adults of all ages studied

thus far, ranging from 3 to 60 y.

Limitation

Only two articles have been published addressed

paediatric studies
Lack of long-term follow-up(Longest with 4 yr
followup studying maintenance of reduction in
AHI)
All of the other studies spanned 2 to 6 mo.

 Thanks for your attension