UCLH offering patients with sleep apnœa a choice of nerve stimulators

UCLH offering patients with sleep apnœa a choice of nerve stimulators

UCLH is the first NHS centre in the UK to offer patients suffering from obstructive sleep apnœa (OSA) a choice of nerve stimulation devices to manage their condition.

This is a marked improvement in the offering to these patients, whose current first line treatment is continuous positive airway pressure (CPAP). CPAP is a machine which requires users to wear a mask at night to receive pressurised air, and many patients find it difficult to get used to sleeping with this machine.

Earlier this month, UCLH implanted the first two patients in the UK with a small chip under the chin to help maintain the airway open during the night and prevent apnœa events. It is called the Genio Nyxoah bilateral hypoglossal nerve stimulator and is one of two types that the UCLH team are offering patients.

The other is the Inspire hypoglossal nerve stimulator and UCLH implanted the first female patient in the UK in June. The patient returned to UCLH last week to submit a sleep study and on Monday learnt how much her sleep has improved by comparing the results to an earlier study she undertook before the implant.

The surgeries were carried out by UCLH consultant ENT and sleep surgeon Ryan Chin Taw Cheong, who said: “We are very pleased to be the first hospital in the UK to offer a choice of hypoglossal nerve stimulators for OSA patients who are unable to tolerate CPAP.

"This new technology will allow us to offer an effective personalised treatment option to a wide range of patients as each implant has unique characteristics which can be matched to a patient’s needs.”

The hypoglossal nerve stimulator is a novel therapy for patients with moderate to severe OSA. A device is implanted surgically underneath the patient’s chin and is managed by the patient so that gentle pulses move the the tongue forward to maintain the upper airway open throughout the night and improve the quality of breathing and sleep overnight.

The surgical procedures take approximately two hours. All were carried out under general anaesthesia in the theatre setting. An implant was placed under the chin through a small incision to overly the nerves that control tongue movement. The patients were discharged the following day after one night of post-operative observation on the ward.

After six to eight weeks of recovery, patients are invited back to an activation and titration clinic to switch on the implant and titrate the level of stimulation to a level that is both effective and comfortable. Patients are taught how to control the implant using an innovative smart phone application or a hand held device.

Obstructive sleep apnœa (OSA) is the most common sleep breathing disorder and is the result of repeated obstruction of the upper airway during sleep. Patients present with a variety of symptoms including snoring, excessive daytime sleepiness, headache and insomnia.

According to the Lancet Respiratory Medicine, an estimated 8 million adults in the United Kingdom have obstructive sleep apnoea. If left untreated, OSA can lead to hypertension, strokes, heart attacks, diabetes and various other issues which affect the quality of life.

The current first line treatment is continuous positive airway pressure (CPAP). CPAP is a machine that blows pressurised air through a mask worn at night. It’s designed to hold the patient’s airway open while they sleep.

However, the machine can be uncomfortable for many patients, and published data over a 20-year time frame revealed a CPAP non-adherence rate of 34.1% which leaves a large number of patients without effective treatment options.

In addition, OSA has been considered a male disease, but it is prevalent in both sexes and women have been underrepresented in clinical trials. An editorial in the Journal of Clinical Sleep Medicine in 2022 called for investigators running clinical trials to make more effort to recruit female participants as very little data for women exists.

“In the meantime, the diagnosis and treatment of OSA in women of all ages will continue to be carried out by extrapolating the procedures usually performed in middle-aged men, which does not seem to be the most appropriate practice,” the editorial said.

Mr Cheong said: “OSA is currently underdiagnosed in women, who have unique anatomical and physiological considerations that should be paid attention. This procedure is only suitable for a small number of patients who meet the strict selection criteria and have been optimised by their secondary care sleep clinics with demonstrable failure of CPAP.’

Natalie Boller, 63, of East Sussex received the Genio Nyxoah implant on Wednesday 4 December.

“About ten years ago my husband made me aware that I was waking up during the night gasping and choking. He said he was worried about me and encouraged me to go and see a doctor. We were living in the US at the time and the doctor there suggested a mouth appliance which was extremely uncomfortable and bulky and I just could not tolerate it.

“We eventually moved to the UK and the doctors here suggested CPAP as the gold standard of treatment. I tried CPAP for a whole year, changing masks to try and find something which worked for me but I just could not get comfortable with it. I would stay awake half the night trying to fall asleep with this mask on my face. 

“After about a year, I sent the machine back to the hospital and a new mouth appliance was suggested. This one was less bulky but still quite uncomfortable and I could not fall asleep with it.

“For many years now, what I’ve been doing is falling asleep without the appliance and when things get really bad, my husband wakes me up and prompts me to wear the device. Because I’m in such a sleepy state I manage to tolerate it better and usually manage to fall asleep again. However, when I heard about this implant, I immediately said I was very interested in trying it because I really want to find something which works for me.”

Olivia Rushton, 48, of Northamptonshire received the Inspire implant at the end of June.

“I first realised I snored in my late 20s. At first, I just laughed it off, but my partner started to wear earplugs and was really struggling to sleep next to me. I tried nasal strips, clips and mouth guards with no success.

“I went to my GP in my early 30s to see if there was anything to be done to help. They referred me to ENT saying that the problem could be a polyp or deviated septum. ENT suggested turbinate reduction surgery, but advised that it would not necessarily reduce my snoring, so I didn't have it done.

“Another ten years passed and I was exhausted, struggling to maintain my weight and still had an unhappy partner. He came with me to the GP and mentioned that my breathing stopped suddenly when I was asleep and I sounded like I was gasping for breath. This led the GP to test me for sleep apnœa and found my Epworth Sleepiness Scale score warranted a referral to a sleep clinic.

“They got me to do a home sleep study (blood oxygen oximetry) overnight at home, I was diagnosed with moderate sleep apnœa. They offered no therapy, but told me to change my habits, lose weight, and reduce alcohol and caffeine. Needless to say, when you're struggling with tiredness and poor-quality sleep, none of that is easy, especially as a female in your 40s.

“Three years later I changed my GP and asked for a referral to a different sleep clinic. That was a much more positive experience. I was given a CPAP machine and diagnosed with severe sleep apnœa. More importantly, I wasn't made to feel like it was my fault, they said it was not weight-related in my case, but anatomical. My tongue falls back when I am asleep and blocks my airway.

“The CPAP machine helped to some degree; it reduced the apnœas, but not enough. I also struggled to wear the mask for longer than a couple of hours a night, as it constantly operated at full pressure, which would wake me up. I also started to suffer with dry and red skin where the mask sat, hair breakage, sore teeth and receding gums. I decided to hunt for an alternative solution.

“I found some information online about the sleep team at UCLH. I got in touch and asked if they could see me. I was told to get my GP to refer me and they did. Thankfully, this was just the right time as they were testing sleep apnœa patients for compatibility with the Inspire implant, a device which sends a small current from the implant to the back of your tongue, pushing it forward. I did a few tests and was told I was a suitable candidate. Mr Cheong and his team did the operation at the end of June and the device was activated at the end of July, as I had recovered from the surgery very quickly."