Origins of and implementation concepts for upper airway stimulation therapy for obstructive sleep apnea  Kingman P. Strohl, M.D., Jonathan Baskin, M.D., Colleen Lance, M.D., Diana Ponsky, M.D., Mark Weidenbecher, M.D., Madeleine Strohl, B.A., Motoo Yamauchi, M.D.  Respiratory Investigation  Volume 54, Issue 4, Pages 241-249 (July 2016) DOI: 10.1016/j.resinv.2016.01.006 Copyright © 2016 Terms and Conditions

Fig. 1 The four pathogenic pathways that in combination lead to recurrent OSA and to the development of the syndrome. If inadequate muscle activation could be reversed, even by itself, recurrent sleep apnea could be reversed at least in a subset of patients. Upper airway muscle and nerve stimulations are collectively called neurotherapeutics. Respiratory Investigation 2016 54, 241-249DOI: (10.1016/j.resinv.2016.01.006) Copyright © 2016 Terms and Conditions

Fig. 2 In this strip chart polysomnogram recording (approximately 2min), the stimulator is turned ON (as verified by the bursting of the chin EMG and then turned OFF, and then turned ON again. Abruptly, when the stimulator is turned OFF, there is upper airway obstruction, as illustrated by the flat nasal pressure signal, continued respiratory efforts, and a fall in oxygen saturation. (The thermistor signal is a thermal drift.) EEG=electroencephalogram. EOG=electrooculogram or eye movements. EMG=chin electromyogram. Snore=snore signal by microphone. THERM=thermistor at the nose for airflow. Nasal=nasal pressure transducer for flow. Chest and Abdm=chest and abdomen efforts, respectively, by inductance methods. SaO2=oxygen saturation by oximetry. Respiratory Investigation 2016 54, 241-249DOI: (10.1016/j.resinv.2016.01.006) Copyright © 2016 Terms and Conditions

Fig. 3 These bars represent the results of the STAR trial for the Inspire therapy from baseline to 36 months. The median values (as the data are not normally distributed) of the apnea–hypopnea index and oxygen desaturation index are provided in the bar graph on the right. The subjective outcomes of the Epworth Sleepiness Scale (ESS) and functional outcomes of sleep questionnaire are also shown. There are significant differences (p<0.001) between the baseline and each of the time points. Further discussion of the results is in the review. Respiratory Investigation 2016 54, 241-249DOI: (10.1016/j.resinv.2016.01.006) Copyright © 2016 Terms and Conditions

Fig. 4 The concepts for the development of a case management plan for a center in terms of patient flow (left column) and system issues (right column). Respiratory Investigation 2016 54, 241-249DOI: (10.1016/j.resinv.2016.01.006) Copyright © 2016 Terms and Conditions