‘Wearables and nearables’ in obstructive sleep apnoea

A technologically and clinically grounded talk on advances in diagnosis and management of obstructive sleep apnoea (OSA) was presented at the Irish Thoracic Society Annual Scientific Meeting.

During his talk, Dr John Garvey, Consultant Respiratory Physician and Sleep Laboratory Director, St Vincent’s University Hospital, and Adjunct Assistant Clinical Professor, University College Dublin, acknowledged the existence of “very little data from an Irish perspective” regarding OSA prevalence. He referenced a recent cross-sectional national survey of validated questionnaires regarding sleep-related issues and disorders that showed a symptom profile “very suggestive of undiagnosed OSA” in around 15 per cent of the Irish population, as well as a high prevalence of restless leg syndrome, diagnosed OSA, and diagnosed insomnia.

“It does appear that sleep conditions are prevalent. We seem to have an association within the Irish population with cardio-metabolic conditions and respiratory conditions. There’s also a high association with musculoskeletal disorders. Morbidity and mortality are even worse for these patients when they have OSA too.”

Dr Garvey also emphasised that falling asleep at the wheel is more likely and occurs more frequently, among people with OSA.

‘Wearables and nearables’

Dr Garvey introduced the conference to a range of “new diagnostic modalities that have the capacity to move away from PSG” (polysomnography) in the diagnosis of OSA, including the French-made Withings smartwatch and sleep mat that are now approved by the US Food and Drug Administration (FDA) for the detection of the disorder, as well as the detection of atrial fibrillation and the measurement of oxygen saturations.

“They have a remote patient monitoring programme, called Withings RPM, and in that they have weighing scales, blood pressure monitors, these sleep devices such as the mat, and thermometers, and it all feeds in and gives feedback on your health.”

Dr Garvey admitted that he could not verify the accuracy of the Withings devices, but to demonstrate the watch’s capabilities, used a light-hearted example of his own haemodynamic readings while watching the All-Ireland hurling final, during which he received repeated alerts about his heart rate.

An overview was provided of various other devices that Dr Garvey termed “wearable and nearables”, including commercial technology like Apple and Android smartwatches, and other clinically focused tools. “It doesn’t tell you that your AHI (apnoea-hypopnoea index) is 50,” Dr Garvey said about the technology, “it gives an alert saying you are at risk of OSA.”

“They do seem to be reasonably accurate in terms of what they are presenting,” stated Dr Garvey, who described the capabilities of these devices. He added that the majority of patients internationally are still going through traditional diagnostic pathways, such as PSG and home apnoea tests, despite the recent approval of several technologies. Delegates heard that a total of nine devices have now been FDA-approved for the detection of OSA, with some being introduced and used in Ireland and the UK. The meeting received an overview of the mechanisms by which the various devices operate and utilise “the potential of AI” (artificial intelligence) for optimal results.

Pharmacological advances

Moving from technology to pharmacology, Dr Garvey said that “conventionally, we think of OSA as an obesity-related collapsibility of the upper airway, but there’s a lot more involved”. He told delegates that until very recently, noradrenergic and anti-muscarinic agents have been the primary focus of pharmacological OSA management, before presenting the emerging evidence for the use of incretin-based therapies.

Dr Garvey talked about the “multiple physiological effects” of glucagon-like peptide-1 (GLP-1) in the body, and presented data from the STRIFE trial, which evaluated the efficacy of daily liraglutide in people with obesity. He told attendees that he had referred several of his patients to the trial, and that they experienced “dramatic results” beyond merely weight loss. “The first patient lost one-third of his body weight. His chronic back pain, his OSA with an AHI of 70, his diabetes, and hypertension all resolved,” Dr Garvey said.

He went on to explore positive data from various randomised controlled trials (RCTs) investigating the effects of other GLP-1 agents such as semaglutide and tirzepatide, referencing RCTs of patients with moderate-to-severe OSA that were treated with tirzepatide and achieved a “dramatic fall in weight” as well as a significant reduction in AHI. “The effects are profound,” Dr Garvey told delegates. He presented findings demonstrating a range of additional benefits from using these drugs, as well as the advantages of bariatric surgery in both OSA and overall health.

Proceeding to an overview of non-pharmacological interventions for OSA, Dr Garvey described hypoglossal nerve stimulation, noting that several versions are available. “It seems to have benefits for patients, with clinically meaningful improvements in AHI,” he said. The conference also heard that day-time training of tongue muscles is a technique used by some practitioners. “The idea is to strengthen muscle tone of the tongue and that patients will have a residual effect overnight,” he explained, adding that the technique is “unlikely effective in supine REM [rapid eye movement] sleep due to the physiological drop in muscle tone” during that phase.

Concluding his talk, Dr Garvey said: “There is a little bit more happening, things are progressing. We’re struggling with the numbers of referrals that we have. If you have wearables and nearables that are giving messages like ‘you might have moderate or severe OSA’, more patients will be seeking referral. To use these new modalities, we’re going to have to look at integrating with platforms and AI to try to improve things. Maybe GLP-1 agonists will improve things dramatically over the next few years.”