Treatment-Emergent Central Sleep Apnea (TECSA) with Chronic Use of Mandibular Advancement Device (MAD): A Case Series

Existing studies on TECSA with MAD usage suggests that TECSA occurs only during the initial MAD treatment and resolves with no long-term concerns. Here we discuss five cases of TECSA arising in patients on chronic MAD therapy and indications this may present for follow-up MAD management.

Search of the University of Vermont (UVM) sleep study database (2013–2023) identified five cases of split night polysomnogram (SN-PSG) where patients decided to use only their MAD during the therapeutic portion of the study that followed baseline PSG recording. Respiratory events were scored according to AASM 2012 guidelines. Obstructive apnea (OA), obstructive hypopnea (OH), mixed apnea (MA), and central apnea (CA) were analyzed before and after MAD application. Indices were calculated as number of episodes/hour.

Mean age of patients was 69 ± 6.0 years (2 females, 3 males). All patients had ≥ 82 days of MAD usage (Range: 82 days-20 years). MAD use predictably showed a decrease in obstructive hypopnea index (OHI) in 80% of patients (Mean OHI_baseline: 12.2 ± 9.2; Mean OHI_MAD: 7.2 ± 4.3). Interestingly, all patients experienced an increase in central apnea index (CAI) (Mean CAI_baseline: 0.7 ± 1.3; Mean CAI_MAD: 5.8 ± 6.7).

These data suggest that TECSA can occur with use of a MAD after chronic adherence to the device. This may suggest a persistent central breathing sensitivity related to changes in respiratory triggers in certain patients. Careful monitoring of patients with MAD is, therefore, warranted and may require repeated PSG testing in patients on MAD therapy.