Lateral Wall Collapse From Sleep Endoscopy and Airflow Shape Predicts Hypoglossal Nerve Stimulation Efficacy in Obstructive Sleep Apnea

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Abstract Rationale: Patient selection for hypoglossal nerve stimulation (HGNS) for obstructive sleep apnea (OSA) requires assessment of the pharyngeal site of collapse using drug-induced sleep endoscopy (DISE). The current study addresses two key knowledge gaps: First, we prospectively assessed whether, among HGNS candidates, reduced HGNS efficacy is associated with oropharyngeal lateral wall (OLW) collapse (Aim 1). Second, given DISE is a resource-intensive procedure that delays treatment, we evaluate whether a recently-developed non-invasive method for identifying OLW collapse using airflow shapes is associated with reduced HGNS efficacy (Aim 2). Methods: Patients who underwent DISE, HGNS implantation, and follow-up sleep testing were included in Aim 1 (n=347). For Aim 2, airflow data estimating OLW collapse probability (Pr. OLW) were collected during DISE via pneumotachograph (n=133, DISE Flow cohort). In a separate cohort, airflow data was obtained from home sleep testing (Nox A1) via nasal cannula for validation (n=41, HST cohort). Pr. OLW was computed from our validated flow shape analysis model. Linear regression models quantified the association between HGNS efficacy (%AHI reduction from baseline) and DISE-determined OLW collapse (Aim 1) or flow-shape-determined OLW collapse (likelihood score per 2SD; Aim 2), adjusting for baseline AHI. A probability cutoff for OLW collapse was developed to categorize patients into likely HGNS successes (who may skip DISE), and those needing further assessment (e.g., DISE). This cutoff maximized the difference in HGNS efficacy from the DISE Flow cohort and then was validated in the HST cohort. In both cohorts, we quantified the degree to which HGNS efficacy was greater in “likely successes” (Pr. OLW>0.6) versus patients “needing further assessment” using the same modelling approach as above. Results: Compared to non-OLW collapse, patients with DISE-determined OLW collapse had lower HGNS efficacy [95%CI] by -13.9%[-26.7,-3.1]. Increased flow-shape-determined OLW collapse probability was associated with reduced HGNS efficacy in both DISE Flow (-19.4%[-33.1,-7.7]) and HST (-30.3 [-61.6, -7.6]%) cohorts. Further, patients in the needs further assessment group (Pr. OLW>0.60, n=30/133) exhibited lower HGNS efficacy than patients in the likely success group (n=103/133), by -20.6 [-35.7,-7.9]% (Figure 1B). Validation in HST cohort also demonstrated lower HGNS efficacy in the needs further assessment group (n=25/41) versus likely successes (Figure 1C), by -21.7 [-46.3,-3.2], p=0.020. Conclusion: This study prospectively validates OLW collapse as a key factor in HGNS failure and shows that airflow-based identification of OLW collapse can effectively estimate HGNS efficacy, presenting a significant advancement in opportunities for patient selection for HGNS.

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