Позиционно-зависимые нарушения дыхания во сне: современное состояние проблемы и перспективы позиционной терапии

Позиционно-зависимые нарушения дыхания во сне, прежде всего позиционное обструктивное апноэ сна (ОАС), представляют собой особый фенотип заболевания, характеризующийся значительной вариабельностью тяжести дыхательных нарушений в зависимости от положения тела. Согласно данным, накопленным за последние десятилетия, до 60% пациентов с ОАС демонстрируют значимую позиционную зависимость, при этом у 20–30% заболевание регистрируется исключительно в положении на спине (изолированное позиционное ОАС). В статье подробно рассмотрены современные представления об эпидемиологии, патофизиологии, особенностях клинической картины и факторах риска развития позиционно-зависимых нарушений дыхания во сне. Особое внимание уделено роли позиционной терапии (ПТ) как перспективного метода лечения, особенно у пациентов с легкой и умеренной формой заболевания. Представлены данные о высокой эффективности и переносимости современных вибротактильных устройств для ПТ, способных значительно снизить степень тяжести заболевания. Рассматриваются результаты рандомизированных контролируемых исследований и метаанализов, подтверждающие сопоставимость эффективности ПТ с другими методами лечения ОАС, включая терапию положительным давлением в верхних дыхательных путях (ПАП-терапию) и ортодонтические устройства. Обсуждаются перспективы комбинированного подхода, необходимость индивидуализации терапии и дальнейших исследований в контексте достижения долгосрочного клинического эффекта, высокой приверженности к терапии и улучшения качества жизни пациентов. Статья может быть полезна как для врачей медицины сна, так и для специалистов смежных медицинских специальностей, сталкивающихся в своей практике с проблемами храпа и нарушениями дыхания во сне.

1. Bahammam AS. Sleep from an Islamic perspective. Ann Thorac Med. 2011;6(4):187–192. https://doi.org/10.4103/1817-1737.84771.

2. Ancoli-Israel S. “Sleep is not tangible” or what the Hebrew tradition has to say about sleep. Psychosom Med. 2001;63(5):778–787. https://doi.org/10.1097/00006842-200109000-00011.

3. Cartwright RD. Effect of sleep position on sleep apnea severity. Sleep. 1984;7(2):110–114. https://doi.org/10.1093/sleep/7.2.110.

4. Oksenberg A, Silverberg DS. The effect of body posture on sleep-related breathing disorders: facts and therapeutic implications. Sleep Med Rev. 1998;2(3):139–162. https://doi.org/10.1016/s1087-0792(98)90018-1.

5. Permut I, Diaz-Abad M, Chatila W, Crocetti J, Gaughan JP, D’Alonzo GE, Krachman SL. Comparison of positional therapy to CPAP in patients with positional obstructive sleep apnea. J Clin Sleep Med. 2010;6(3):238–243. Available at: https://pubmed.ncbi.nlm.nih.gov/20572416/.

6. Landry SA, Beatty C, Thomson LDJ, Wong AM, Edwards BA, Hamilton GS, Joosten SA. A review of supine position related obstructive sleep apnea: Classification, epidemiology, pathogenesis and treatment. Sleep Med Rev. 2023;72:101847. https://doi.org/10.1016/j.smrv.2023.101847.

7. Kavey NB, Blitzer A, Gidro-Frank S, Korstanje K. Sleeping position and sleep apnea syndrome. Am J Otolaryngol. 1985;6(5):373–377. https://doi.org/10.1016/s0196-0709(85)80015-6.

8. Lloyd SR, Cartwright RD. Physiologic basis of therapy for sleep apnea. Am Rev Respir Dis. 1987;136(2):525–526. https://doi.org/10.1164/ajrccm/136.2.525b.

9. Oksenberg A, Silverberg DS, Arons E, Radwan H. Positional vs nonpositional obstructive sleep apnea patients: anthropomorphic, nocturnal polysomnographic, and multiple sleep latency test data. Chest. 1997;112(3):629–639. https://doi.org/10.1378/chest.112.3.629.

10. George CF, Millar TW, Kryger MH. Sleep apnea and body position during sleep. Sleep. 1988;11(1):90–99. https://doi.org/10.1093/sleep/11.1.90.

11. Pevernagie DA, Shepard JWJr. Relations between sleep stage, posture and effective nasal CPAP levels in OSA. Sleep. 1992;15(2):162–167. https://doi.org/10.1093/sleep/15.2.162.

12. Cartwright RD, Lloyd S, Lilie J, Kravitz H. Sleep position training as treatment for sleep apnea syndrome: a preliminary study. Sleep. 1985;8(2):87–94. https://doi.org/10.1093/sleep/8.2.87.

13. Richard W, Kox D, den Herder C, Laman M, van Tinteren H, de Vries N. The role of sleep position in obstructive sleep apnea syndrome. Eur Arch Otorhinolaryngol. 2006;263(10):946–950. https://doi.org/10.1007/s00405-006-0090-2.

14. Mador MJ, Kufel TJ, Magalang UJ, Rajesh SK, Watwe V, Grant BJ. Prevalence of positional sleep apnea in patients undergoing polysomnography. Chest. 2005;128(4):2130–2137. https://doi.org/10.1378/chest.128.4.2130.

15. Sabil A, Blanchard M, Trzepizur W, Goupil F, Meslier N, Paris A et al. Positional obstructive sleep apnea within a large multicenter French cohort: prevalence, characteristics, and treatment outcomes. J Clin Sleep Med. 2020;16(12):2037–2046. https://doi.org/10.5664/jcsm.8752.

16. Heinzer R, Petitpierre NJ, Marti-Soler H, Haba-Rubio J. Prevalence and characteristics of positional sleep apnea in the HypnoLaus population-based cohort. Sleep Med. 2018;48:157–162. https://doi.org/10.1016/j.sleep.2018.02.011.

17. Kim EJ, Choe H, Kang SM, Choi JH, Kwon SY, Lee SH. The Prevalence and Characteristics of Positional Sleep Apnea in Korea. Korean J Otorhinolaryngol-Head Neck Surg. 2009;52(5):407–412. https://doi.org/10.3342/kjorl-hns.2009.52.5.407.

18. Mo JH, Lee CH, Rhee CS, Yoon IY, Kim JW. Positional dependency in Asian patients with obstructive sleep apnea and its implication for hypertension. Arch Otolaryngol Head Neck Surg. 2011;137(8):786–790. https://doi.org/10.1001/archoto.2011.122.

19. Ravesloot MJ, Frank MH, van Maanen JP, Verhagen EA, de Lange J, de Vries N. Positional OSA part 2: retrospective cohort analysis with a new classification system (APOC). Sleep Breath. 2016;20(2):881–888. https://doi.org/10.1007/s11325-015-1206-y.

20. Joosten SA, Hamza K, Sands S, Turton A, Berger P, Hamilton G. Phenotypes of patients with mild to moderate obstructive sleep apnoea as confirmed by cluster analysis. Respirology. 2012;17(1):99–107. https://doi.org/10.1111/j.1440-1843.2011.02037.x.

21. Oksenberg A, Dynia A, Nasser K, Gadoth N. Obstructive sleep apnoea in adults: body postures and weight changes interactions. J Sleep Res. 2012;21(4):402–409. https://doi.org/10.1111/j.1365-2869.2011.00988.x.

22. Oksenberg A, Goizman V, Eitan E, Nasser K, Gadoth N, Leppänen T. Obstructive sleep apnea: do positional patients become nonpositional patients with time? Laryngoscope. 2020;130(9):2263–2268. https://doi.org/10.1002/lary.28387.

23. Joosten SA, Khoo JK, Edwards BA, Landry SA, Naughton MT, Dixon JB, Hamilton GS. Improvement in obstructive sleep apnea with weight loss is dependent on body position during sleep. Sleep. 2017;40(5):zsx047. https://doi.org/10.1093/sleep/zsx047.

24. Penzel T, Möller M, Becker HF, Knaack L, Peter JH. Effect of sleep position and sleep stage on the collapsibility of the upper airways in patients with sleep apnea. Sleep. 2001;24(1):90–95. https://doi.org/10.1093/sleep/24.1.90.

25. Remmers JE, deGroot WJ, Sauerland EK, Anch AM. Pathogenesis of upper airway occlusion during sleep. J Appl Physiol Respir Environ Exerc Physiol. 1978;44(6):931–938. https://doi.org/10.1152/jappl.1978.44.6.931.

26. Skinner MA, Kingshott RN, Jones DR, Homan SD, Taylor DR. Elevated posture for the management of obstructive sleep apnea. Sleep Breath. 2004;8(4):193–200. https://doi.org/10.1007/s11325-004-0193-1.

27. Eckert DJ, White DP, Jordan AS, Malhotra A, Wellman A. Defining phenotypic causes of obstructive sleep apnea. Identification of novel therapeutic targets. Am J Respir Crit Care Med. 2013;188(8):996–1004. https://doi.org/10.1164/rccm.201303-0448OC.

28. Ong JS, Touyz G, Tanner S, Hillman DR, Eastwood PR, Walsh JH. Variability of human upper airway collapsibility during sleep and the influence of body posture and sleep stage. J Sleep Res. 2011;20(4):533–537. https://doi.org/10.1111/j.1365-2869.2011.00925.x.

29. Joosten SA, Edwards BA, Wellman A, Turton A, Skuza EM, Berger PJ, Hamilton GS. The Effect of Body Position on Physiological Factors that Contribute to Obstructive Sleep Apnea. Sleep. 2015;38(9):1469–1478. https://doi.org/10.5665/sleep.4992.

30. Terrill PI, Edwards BA, Nemati S, Butler JP, Owens RL, Eckert DJ et al. Quantifying the ventilatory control contribution to sleep apnoea using polysomnography. Eur Respir J. 2015;45(2):408–418. https://doi.org/10.1183/09031936.00062914.

31. Bearpark H, Elliott L, Grunstein R, Cullen S, Schneider H, Althaus W, Sullivan C. Snoring and sleep apnea. A population study in Australian men. Am J Respir Crit Care Med. 1995;151(5):1459–1465. https://doi.org/10.1164/ajrccm.151.5.7735600.

32. Heinzer R, Vat S, Marques-Vidal P, Marti-Soler H, Andries D, Tobback N et al. Prevalence of sleep-disordered breathing in the general population: the HypnoLaus study. Lancet Respir Med. 2015;3(4):310–318. https://doi.org/10.1016/S2213-2600(15)00043-0.

33. de Araujo Dantas AB, Gonçalves FM, Martins AA, Alves GÂ, Stechman-Neto J, Corrêa CC et al. Worldwide prevalence and associated risk factors of obstructive sleep apnea: a meta-analysis and meta-regression. Sleep Breath. 2023;27(6):2083–2109. https://doi.org/10.1007/s11325-023-02810-7.

34. Chan CH, Wong BM, Tang JL, Ng DK. Gender difference in snoring and how it changes with age: systematic review and meta-regression. Sleep Breath. 2012;16(4):977–986. https://doi.org/10.1007/s11325-011-0596-8.

35. Campos AI, García-Marín LM, Byrne EM, Martin NG, Cuéllar-Partida G, Rentería ME. Insights into the aetiology of snoring from observational and genetic investigations in the UK Biobank. Nat Commun. 2020;11(1):817. https://doi.org/10.1038/s41467-020-14625-1.

36. Appleton SL, Gill TK, Lang CJ, Taylor AW, McEvoy RD, Stocks NP et al. Prevalence and comorbidity of sleep conditions in Australian adults: 2016 Sleep Health Foundation national survey. Sleep Health. 2018;4(1):13–19. https://doi.org/10.1016/j.sleh.2017.10.006.

37. Ravesloot MJ, van Maanen JP, Dun L, de Vries N. The undervalued potential of positional therapy in position-dependent snoring and obstructive sleep apnea-a review of the literature. Sleep Breath. 2013;17(1):39–49. https://doi.org/10.1007/s11325-012-0683-5.

38. Bignold JJ, Mercer JD, Antic NA, McEvoy RD, Catcheside PG. Accurate position monitoring and improved supine-dependent obstructive sleep apnea with a new position recording and supine avoidance device. J Clin Sleep Med. 2011;7(4):376–383. https://doi.org/10.5664/JCSM.1194.

39. Choi JH, Park TY, Hong JH, Kim SJ, Park DS, Miyazaki S et al. Efficacy study of a vest-type device for positional therapy in position dependent snorers. Sleep Biol Rythms. 2009;7:181–187. https://doi.org/10.1111/j.1479-8425.2009.00401.x.

40. Zuberi NA, Rekab K, Nguyen HV. Sleep apnea avoidance pillow effects on obstructive sleep apnea syndrome and snoring. Sleep Breath. 2004;8(4):201–207. https://doi.org/10.1007/s11325-004-0201-5.

41. Bignold JJ, Deans-Costi G, Goldsworthy MR, Robertson CA, McEvoy D, Catcheside PG, Mercer JD. Poor long-term patient compliance with the tennis ball technique for treating positional obstructive sleep apnea. J Clin Sleep Med. 2009;5(5):428–430. https://doi.org/10.5664/jcsm.27597.

42. Sarkis LM, Jones AC, Ng A, Pantin C, Appleton SL, MacKay SG. Australasian Sleep Association position statement on consensus and evidence based treatment for primary snoring. Respirology. 2023;28(2):110–119. https://doi.org/10.1111/resp.14443.

43. Bradley TD, Logan AG, Kimoff RJ, Sériès F, Morrison D, Ferguson K et al. Continuous positive airway pressure for central sleep apnea and heart failure. N Engl J Med. 2005;353(19):2025–2033. https://doi.org/10.1056/NEJMoa051001.

44. Joho S, Oda Y, Hirai T, Inoue H. Impact of sleeping position on central sleep apnea/Cheyne-Stokes respiration in patients with heart failure. Sleep Med. 2010;11(2):143–148. https://doi.org/10.1016/j.sleep.2009.05.014.

45. Szollosi I, Roebuck T, Thompson B, Naughton MT. Lateral sleeping position reduces severity of central sleep apnea/Cheyne-Stokes respiration. Sleep. 2006;29(8):1045–1051. https://doi.org/10.1093/sleep/29.8.1045.

46. Pinna GD, Lovagnini M, Robbi E, Dacosto E, La Rovere MT, Maestri R. Effect of lateral position on rostral fluid shift and relationship to severity of Cheyne-Stokes respiration in heart failure patients. Sleep Breath. 2024;28(2):789–796. https://doi.org/10.1007/s11325-023-02969-z.

47. Veasey SC, Guilleminault C, Strohl KP, Sanders MH, Ballard RD, Magalang UJ. Medical therapy for obstructive sleep apnea: a review by the Medical Therapy for Obstructive Sleep Apnea Task Force of the Standards of Practice Committee of the American Academy of Sleep Medicine. Sleep. 2006;29(8):1036–1044. https://doi.org/10.1093/sleep/29.8.1036.

48. Kushida CA, Littner MR, Morgenthaler T, Alessi CA, Bailey D, Coleman JJr et al. Practice parameters for the indications for polysomnography and related procedures: an update for 2005. Sleep. 2005;28(4):499–521. https://doi.org/10.1093/sleep/28.4.499.

49. Morgenthaler TI, Kapur VK, Brown T, Swick TJ, Alessi C, Aurora RN et al. Practice parameters for the treatment of narcolepsy and other hypersomnias of central origin. Sleep. 2007;30(12):1705–1711. https://doi.org/10.1093/sleep/30.12.1705.

50. Weaver TE, Grunstein RR. Adherence to continuous positive airway pressure therapy: the challenge to effective treatment. Proc Am Thorac Soc. 2008;5(2):173–178. https://doi.org/10.1513/pats.200708-119MG.

51. Littner MR. Mild obstructive sleep apnea syndrome should not be treated. Con J Clin Sleep Med. 2007;3(3):263–264. https://doi.org/10.5664/jcsm.26794.

52. Rosenthal L, Gerhardstein R, Lumley A, Guido P, Day R, Syron ML, Roth T. CPAP therapy in patients with mild OSA: implementation and treatment outcome. Sleep Med. 2000;1(3):215–220. https://doi.org/10.1016/s1389-9457(00)00012-5.

53. Oksenberg A, Silverberg D, Offenbach D, Arons E. Positional therapy for obstructive sleep apnea patients: A 6-month follow-up study. Laryngoscope. 2006;116(11):1995–2000. https://doi.org/10.1097/01.mlg.0000237674.66716.a7.

54. Skinner MA, Kingshott RN, Filsell S, Taylor DR. Efficacy of the ‘tennis ball technique’ versus nCPAP in the management of position-dependent obstructive sleep apnoea syndrome. Respirology. 2008;13(5):708–715. https://doi.org/10.1111/j.1440-1843.2008.01328.x.

55. van Maanen JP, Meester KA, Dun LN, Koutsourelakis I, Witte BI, Laman DM et al. The sleep position trainer: a new treatment for positional obstructive sleep apnoea. Sleep Breath. 2013;17(2):771–779. https://doi.org/10.1007/s11325-012-0764-5.

56. Александров АР, Агальцов МВ, Янгиров МА и др. Оценка уровня вибрационного воздействия на качество сна при позиционной терапии. В: Полуэктов МГ, Стрыгина КН (ред.). Актуальные вопросы сомнологии: материалы конференции. Москва, 15–16 ноября 2024 г. М.: ФГАОУ ВО Первый МГМУ им. И.М. Сеченова Минздрава России (Сеченовский Университет); 2024. С. 9. Режим доступа: https://sechenov-somnolog.confreg.org/libs/files/sbornik_tezisov_somnologiya_2024.pdf.

57. Ravesloot MJL, White D, Heinzer R, Oksenberg A, Pepin JL. Efficacy of the new generation of devices for positional therapy for patients with positional obstructive sleep apnea: a Systematic review of literature and meta-analysis. J Clin Sleep Med. 2017;13(6):813–824. https://doi.org/10.5664/jcsm.6622.

58. van Maanen JP, Richard W, Van Kesteren ER, Ravesloot MJ, Laman DM, Hilgevoord AA, de Vries N. Evaluation of a new simple treatment for positional sleep apnoea patients. J Sleep Res. 2012;21(3):322–329. https://doi.org/10.1111/j.1365-2869.2011.00974.x.

59. Barnes H, Edwards BA, Joosten SA, Naughton MT, Hamilton GS, Dabscheck E. Positional modification techniques for supine obstructive sleep apnea: A systematic review and meta-analysis. Sleep Med Rev. 2017;36:107–115. https://doi.org/10.1016/j.smrv.2016.11.004.

60. Laub RR, Tønnesen P, Jennum PJ. A Sleep Position Trainer for positional sleep apnea: a randomized, controlled trial. J Sleep Res. 2017;26(5):641–650. https://doi.org/10.1111/jsr.12530.

61. Jokic R, Klimaszewski A, Crossley M, Sridhar G, Fitzpatrick MF. Positional treatment vs continuous positive airway pressure in patients with positional obstructive sleep apnea syndrome. Chest. 1999;115(3):771–781. https://doi.org/10.1378/chest.115.3.771.

62. Berry RB, Uhles ML, Abaluck BK, Winslow DH, Schweitzer PK, Gaskins RA Jr et al. NightBalance Sleep Position Treatment Device Versus Auto-Adjusting Positive Airway Pressure for Treatment of Positional Obstructive Sleep Apnea. J Clin Sleep Med. 2019;15(7):947–956. https://doi.org/10.5664/jcsm.7868.

63. Mok Y, Tan A, Hsu PP, Seow A, Chan YH, Wong HS et al. Comparing treatment effects of a convenient vibratory positional device to CPAP in positional OSA: a crossover randomised controlled trial. Thorax. 2020;75(4):331–337. https://doi.org/10.1136/thoraxjnl-2019-213547.

64. Benoist L, de Ruiter M, de Lange J, de Vries N. A randomized, controlled trial of positional therapy versus oral appliance therapy for position-dependent sleep apnea. Sleep Med. 2017;34:109–117. https://doi.org/10.1016/j.sleep.2017.01.024.

65. de Ruiter MHT, Benoist LBL, de Vries N, de Lange J. Durability of treatment effects of the Sleep Position Trainer versus oral appliance therapy in positional OSA: 12-month follow-up of a randomized controlled trial. Sleep Breath. 2018;22(2):441–450. https://doi.org/10.1007/s11325-017-1568-4.

66. Mohamed AM, Mohammed OM, Liu S, Al-Balaa M, Al-Warafi LA, Peng SJ, Qiao YQ. Oral appliance therapy vs. positional therapy for managing positional obstructive sleep apnea; a systematic review and meta-analysis of randomized control trials. BMC Oral Health. 2024;24(1):666. https://doi.org/10.1186/s12903-024-04277-8.

67. Dieltjens M, Vroegop AV, Verbruggen AE, Wouters K, Willemen M, De Backer WA et al. A promising concept of combination therapy for positional obstructive sleep apnea. Sleep Breath. 2015;19(2):637–644. https://doi.org/10.1007/s11325-014-1068-8.