The Effects of Nasal

Decongestion on
Obstructive Sleep Apnea
Assembled By: Shweta Chandru
Bhavnani/ 01073180064
Guided by: dr. Christian H
Suswdidanto, Sp. THT-KL
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Introductio
n
- The pathophysiology of Obstructive Sleep Apnea is
complex and remains unclear.
- Research shows that OSA; Heterogenous disorder
contributed by many factors.
- This study is to find the association between Impaired
Nasal Breathing and Sleep Disorders.
- Relationship between nasal patency and sleep unclear.
- Importance of nasal airflow in the pathogenesis of
airway collapse in OSA patients controversial
- Management of disorder: Nasal Surgery.
- Inconsistent improvement of apnoea/ hypopnea index
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- improve AHI
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- Improve Subjective Sleep Quality, sleep
architecture, snoring and daytime sleepiness but
not AHI
.
Maybe due to differences in:
- severity of nasal mucosal lesion associated with
various surgical approaches
- Different OSA phenotypes

- Selection of OSA patients suitable for nasal

surgery improve outcome
- Multilevel obstruction in OSA patients so greater
benefit of nasal surgery in patients.
- Study of Polysomnographic characteristic in NO (Nasal
obstruction predominant) -OSA patients before and
after decongestant use will facilitate personalized
treatment for whom nasal obstruction is the main
factor.
THIS STUDY:
- Effects of nasal patency on sleep quality and breath in
OSA patients by applying nasal decongestant spray.
- Reduce confounding factors; observe interactions
between sleep disturbance and nasal obstruction.
- Randomized, placebo-controlled double-blind
crossover about effects of topical nasal decongestant
on sleep architecture, respiratory events, body position,
Patients Criteria 7
- Must be diagnosed with OSA at OSA Clinical Diagnosis and
Therapy Centre and has not undergone treatment
- 15 OSA patients; 14 males, 25-54 age, BMI (22.8-31.4)
included.
Conditions for enrollment;
1) Typical Symptoms- Snoring, Witnessed Apnoes, Day-time
sleepiness, AHI ≥ 5/h.
2) Subjective chronic impaired nasal breathing and objective nasa
congestion confirmed by nasal endoscopy- all had inferior
turbinate hypertrophy.
3) Absence of obvious pharyngneal narrowing: w/o tonsillar
hypertrophy and Friedman tongue position FTP grade 1 and 2
Exclusion:
1) Previous upper airway surgery
2) Nasal spray treatment within 3 months
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Physical Examination
- Medical History reviewed in detail.
- Aubjective perception of nasal congestion measured by
VAS (visual analogue scale) 0: No nasal congestion, 10:
wholly obstructed nose
- Upper airway assessed by endoscopy
- Physical Exam conducted by same otorhinolaryngologist-
nasal endoscopy, anterior rhinomanometry and
fibrolaryngoscopy.
- Approved by Ethics Committee of Beijing Tongren
Hospital, Beijing, China.
- Detail explanation of study+ Informed consent to
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Design and Protocol

Design Study: randomized, double-blind crossover study
Each does 2 polysomnographic studies; 1 Placebo, 1 treatment in
random order on 2 different nights separated by 48 hour interval
‘wash-out period’
- Avoid confounding: ‘First night effect’; random application of
oxymetazoline (0.05% solution, 0.4ml) and placebo (normal
saline, 0.9% solution, 0.4ml) in each nostril.
- To maintain maximal efficacy: Administered on sleep onset
and 3 hr after.
- Evaluation of quality of sleep improvement assesed by VAS 0:
satisfied, 10: unsatisfied
- Randomization: computer- generated table of random numbers
- Subjects and technician blinded
 Polysomnography 10
- Standard overnight PSG performed on all
patients.
- 4 channel EEG (electroencephalogram)
- 2 channel airflow with oro-nasal thermistor
and nasal pressure canula
- snoring sensor
- respiratory movements
- body position sensor
- submental and anterior tibia EMG
(electromyography)
- Electrocardiography
Data analysis: - Pulse oximeter for O2 saturation.
- 30s epochs and scored manually - Infrared video monitor
- Apnea: ↓ airflow of ≥ 90% lasting for <10s + oxygen desaturation 3% or arousal
- ODI (Oxygen Desaturation Index) : Total no of reductions of ≥ 3% saturation/ hour of
sleep
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Data Analysis and Statistics

- Evaluated by SPSS version 21.0
- Data collected after oxymetazoline or placebo
compared
- Results were presented as means ± SD or median
(P25, P75).
- Data collected after different treatments were
compared by paired t-tests or Wilcoxon rank tests.
- A P value of < 0.05 was considered statistically
significant.
Results VAS in the morning also
improved; 12
Sleep Architecture and Placebo: 6 (5,7)
Quality Oxymetazoline: 5( 3,6)
p= 0.0011

Reduced Stage 1 sleep

Increased REM sleep

Improvement

Reduced Arousal
Index
Results 13
Sleep Disorder Breathing
Events

Significantly reduced

No significant improvement

Prologed hypopnea
after nasal
decongestant
administration
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Results 15
Oxygen Desaturation during
Sleep

Significantly Decreased
(Mean) Significantly
(Lowest)
Increased

Improved nasal
patency, Blood
oxygen saturation
during sleep improved
significantly
Results 16
Distribution and AHI of different sleep positions

No significant
improvement of AHI

No significant
effects on total
sleep time in
supine position
 Discussion 17

• 1980: Experimentally induced nasal obstruction = ⬆number of arousals

and apneas during sleep

⬇ Nasal ⬆ Negative intraluminal ⬆

Patency pressure within upper downstream
airway suction
⬆ Nasal forces collapse
⬆ Oral Breathing Inspiratory
resistance
at the pharyngeal
⬇ retropalatal and level.
retroglossal areas upper airway
more collapsible More severe OSA

• Nasal- anesthesia induced breathing during sleep = complete nasal

obstruction
• Normal mucosa function= patency of upper airway and ventilation 
frequency and severity of apnoea during sleep.
• To diminish confounding:decongestion investigate effects of nasal
 Discussion 18

• Different Proportions and Etiologies of OSA Selection of those

benefit most from nasal airway treatment  Satisfactory outcomes.
Ikoutsourelakis: Baseline Nasal breathing surgery outcome.
Park: Nasal Surgery: ⬇ OSA severity in 56% patients with nasal
obstruction without tonsillar hypertrophy.
• Li: OSA patients with low Friedman tongue position Better
success rate after surgery.
• Absence of tonsillar hypertrophy, Lower Friedman Tongue position,
Upper airway endoscopy select nasal obstruction dominance of
OSA pathophysiology.
• Polysomnographic characteristics studied with and without use of
nasal decongestant.
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Discussion
• Sleep quality (subjective and objective) and saturation level improved
after nasal decongestant.
• AHI ⬇ in REM and NREM sleep.
• After decongestion: AI ⬇ while HI did not improve after nasal patency
improved some apnoea events may have decreased in severity
hypopnea events.
• Prolongations of hypopnea events  both average and longest
durations. nasal decongestant application improve apnoea but not
hypopnea.
• OSA with apnoea as dominant respiratory event more sensitive to
nasal improvement therapy.
• AHI in supine position lowered after application of nasal
decongestant better outcome from nasal patency improvement.
• Observational results  Polysomnography characteristics of AI and
supine AHI greater benefits of nasal treatment.
• Variables related to anatomy/ sleep parameters screening for
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Limitations
• Did not consider functional assesment of upper airway
collapsibility of pharyngeal airway Improved assesment of
patients provision of more appropriate therapy.
• Drug - induced sleep endoscopy needed to investigate upper
airway collapsibility in OSA patients.
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Conclusion
• Topical nasal decongestant; oxymetazoline 
Improve nasal patency  Improve quality,
Apnoea-Hypopnea index and Oxygen Saturation
level during sleep.
• Significant change in apnoea events but no
change in HI.
• AHI in supine position reduced significantly after
nasal decongestion.
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