Hypoglossusstimulation bei OSAS

Zusammenfassung

Anatomische Grundlage der obstruktiven Schlafapnoe (OSA) ist der Kollaps des Pharynx im Schlaf. Er wird als Folge komplexer Interaktionen struktureller und neuromuskulärer Faktoren angesehen. Schlaftiefe und Körperlage wirken dabei modulierend. Obgleich unterschiedliche Obstruktionsorte nachgewiesen werden konnten, ergaben Studien, dass sich die schlafvermittelte Obstruktion oft im Zungengrundgrundbereich manifestiert.

Die funktionelle Druckluftschienung der oberen Atemwege während des Schlafes mittels Continuous Positive Airway Pressure (CPAP) stellt seit über 30 Jahren die Standardtherapie beim obstruktiven Schlafapnoe Syndrom (OSAS) dar. In mehreren Untersuchungen lag die Therapieadhärenz bei etwa 70%. Bei CPAP-Unverträglichkeit bedarf es alternativer operativer und nicht-operativer Therapieformen.

Die funktionelle elektrische Stimulation der oberen Atemwegsmuskeln wurde bereits in den frühen 1980er Jahren untersucht. Studien ergaben, dass eine Stimulation bestimmter Muskelgruppen den Querschnitt der oberen Atemwege vergrößert. Dabei wurde die bedeutende Funktion des N. hypoglossus nachgewiesen. So innerviert der XII. Hirnnerv den M. genioglossus, der im Wesentlichen den vorderen Oropharynx stabilisiert. Im Gegensatz zur kompletten Stimulation des Nervs, der zur Ko-Aktivierung anderer Muskeln (auch verengender Muskeln) führt, bewirkt die selektive Stimulation der weiter zum Kinn gelegenen Nervenäste eine Vorwärtsbewegung des M. genioglossus.

Derzeit in Europa zugelassene Systeme zur Hypoglossusnervstimulation (HNS) sind das Inspire™-System sowie das ImThera™-Gerät. Nach umfangreicher tierexperimenteller und klinischer Überprüfung des Konzeptes der Hypoglossusnervstimulation (HNS) wurden kürzlich die Ergebnisse der multizentrischen, prospektiven STAR-Studie (Stimulation Therapy for Apnea Reduction) mit dem Inspire-System veröffentlicht. Diese Studie ergab, dass die HNS den pharyngealen Kollaps verhindern kann, ohne die Patienten aus dem Schlaf zu wecken. Die HNS mit diesem Gerät führte zu einer signifikanten Verbesserung der objektiven und subjektiven Parameter des Schweregrades einer OSA.

Die elektrische Stimulation des N. hypoglossus ist eine neue Behandlungsmethode für Patienten mit mittelschwerer bis schwerer OSA, die die Standardtherapie nicht tolerieren.

Abstract

Anatomical basis of obstructive sleep apnea (OSA) is the collapse of the pharynx during sleep. It is considered as a result of complex interactions of structural and neuromuscular factors. Depth of sleep and body position have modulating effects. Although different areas of obstruction were identified, studies show that the sleep-mediated obstruction frequently occurs in the base of tongue area.

Continuous positive airway pressure (CPAP) is the standard treatment for obstructive sleep apnea syndrome (OSAS) since more than 30 years. In several studies, treatment compliance was approximately 70%. So CPAP intolerance requires alternative surgical and non-surgical treatments.

Functional electrical stimulation of upper airway muscles was investigated in the early 1980s. Studies have shown that stimulation of certain muscle groups increases the upper airway lumen. The major role of the hypoglossal nerve in upper airway obstruction was detected. The XII. cranial nerve innervates the genioglossus muscle, which stabilizes the anterior oropharynx substantially. Whereas a complete stimulation of the nerve leads to co-activation of other muscles including constrictors, the selective stimulation of anterior nerve branches causes advancement of the genioglossus.

For hypoglossal nerve stimulation (HNS), the Inspire™ system and the ImThera™ device are currently approved in Europe. After extensive studies in animals and clinical examination of the concept of hypoglossal nerve stimulation (HNS), the results of the multicenter, prospective STAR study (Stimulation Therapy for Apnea Reduction) with the Inspire system were recently published. This study revealed that HNS can prevent the pharyngeal collapse without waking up the patient from sleep. The HNS with this device resulted in a significant improvement of both objective and subjective parameters of the severity of OSA.

Electrical stimulation of the hypoglossal nerve is a new treatment for patients with moderate to severe OSA, who do not tolerate standard treatment.

Schlüsselwörter

Hypoglossusstimulation - obstruktives Schlafapnoe Syndrom - Schlafbezogene Atmungsstörung - CPAP-Intoleranz - Hypoglossusnerv

Key words

Upper Airway Stimulation - obstructive sleep apnea - sleep-disordered breathing - CPAP Intolerance - hypoglossal nerve

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