Treatment of obstructive lie in the grave apnea with continuous positive airway compressing (CPAP) is less than ideal.

Treatment of obstructive lie in the grave apnea with continuous positive airway compressing (CPAP) is less than ideal, not because the universal is incorrect but because the delivery is cumbersome and patients find it difficult to adapt to its use. Apart from being anchored to a mask, tubing, and a potentially noisy pressure-generating device, there may be nasal discomfort, nasal congestion, nasal obstruction, claustrophobia, the feeling of being either overventilated or underventilated, and inlet and mask leaks that make acceptance and adherence with nasal CPAP difficult for many patients. Several approaches (1-4) have had a success in overcoming the disadvantages of CPAP including heated humidification, chin straps, treatment of nasal congestion the pair pharmacologically and surgically, use of hypnotics, different signs of interfaces such as nasal cannulas, or a full-face mask (also called an oronasal mask). Despite these approaches, adherence and acceptance are les than ideal. (5)

An alternative that would avoid nasal congestion and obstruction and potentially would make less the claustrophobic feeling from a confining mask would be to deliver CPAP between the walls of the mouth. However, although there are at least brace devices available in the United States that permit oral CPAP, a search of the literature fails to identify a single peer-reviewed thought using such an approach. undivided of these devices is a combination anterior mandibular advancement dental device with an orifice for optional CPAP. (6) The other device is the oral mask, similar to the united examined in the study through Smith et al in this issue of CHEST (see page 689) which fits throughout the lips and seals the orifice with an orifice for delivery of CPAP and an oral retainer that depresse the anterior portion of the tongue. Although the technology is available, many questions about its use remain to be answered.

Smith et al have made a small nevertheless important step forward in validating that oral CPAP is a potentially viable regularity of treating patients with obstructive nap apnea. This preliminary study of seven exposes (five men and two women) addresses a focused and relevant question. Does the use of an oral interface to deliver CPAP breed equivalent pressure-flow curves of the upper airway, indicating that nasal and oral CPAP are potentially therapeutically equivalent? Although it might be seen intuitive that "splinting" the airway with urgency from the nose or chaps would lead to similar consequence s the differing anatomy and geometry of the oral way vs the nasal route raised the possibility that differing presss would be required. The data from this small sample refer to that there are not marked differences in the constraining force required to keep the airway from collapsing and to maintain airway patency without arise limitation (ie, without continued partial upper airway obstruction) during tidal breathing. The authors also allowed subdues to sleep with the oral device without the nose clip, which was used during pressure-flow crook measurements. There was no apparent los of effectiveness (pressure-flow winds were not measured) of oral CPAP. Of note, the squeezing that eliminated flow limitation in this clump of subjects with severe obstructive doze apnea averaged 11 cm [Hsub2]O

While this is a promising start, many questions remain. Those include, among others, patient comfort with differing urgencys the obligatory need to continue the mouth sealed shut all night with the device, further examination of the position of the tongue that might potentially occlude the airway orifice forward an individual basis, the possible ne for heated or room-temperature humidification, the ne for a nose clip to hinder nasal breathing or leakage onward an individual basis, its use with an edentulous patient, the potential that the flexibility of the plastic tissues of the mouth like as the cheeks may bring into view discomfort with distension from cavity between the jaws pressure (particularly if higher urgencys are required), and the possibility of sex differences in answer to oral CPAP. Furthermore, although the contemplation suggests that the airway mechanics are similar during oral and nasal CPAP during non-rapid judgment movement sleep, only a fix upon few measurements were made, and there is no description of whether corpse or head position or rapid organ of vision movement (REM) sleep had any issue on the results. These conditions may potentially affect the springs by putting pressure or stres forward the mouth (head position), according to relaxing the upper airway (REM sleep) or through increasing pressures to prevent airway collapse and maintain airway patency (head position, material substance position, or REM sleep). In addition, as with any occlusion of the aperture there is the hypothetical possibility of the aspiration of stomach satisfactions should the patient regurgitate during the night and not be able to remove the emesis through an occlud opening Of note, this is also a hypothetical possibility with a full-face mask (12) on the contrary there are few if any documented cases of this occurrence

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