Nasal Dilators (Breathe Right Strips and NoZovent) for Snoring and OSA: A Systematic Review and Meta-Analysis

Hindawi Publishing Corporation Pulmonary Medicine Volume 2016, Article ID 4841310, 7 pages http://dx.doi.org/10.1155/2016/4841310 Review Article Nasal Dilators (Breathe Right Strips and NoZovent) for Snoring and OSA: A Systematic Review and Meta-Analysis Macario Camacho,1 Omojo O. Malu,2 Yoseph A. Kram,3 Gaurav Nigam,4 Muhammad Riaz,5 Sungjin A. Song,3 Anthony M. Tolisano,3 and Clete A. Kushida6 1 Tripler Army Medical Center, Division of Otolaryngology, Sleep Surgery and Sleep Medicine, 1 Jarrett White Rd, Tripler AMC, Honolulu, HI 96859, USA 2 Uniformed Services University of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD 20814, USA 3 Tripler Army Medical Center, Division of Otolaryngology-Head & Neck Surgery, Tripler AMC, Honolulu, HI 96859, USA 4 Clay County Hospital, 911 Stacy Burk Drive, Flora, IL 62839, USA 5 Sleep Disorders Center, Sunnyside Community Hospital, 1016 Tacoma Avenue, Sunnyside, WA 98944, USA 6 Department of Psychiatry and Behavioral Sciences, Sleep Medicine Division, Stanford Hospital and Clinics, Redwood City, CA 94063, USA Correspondence should be addressed to Macario Camacho; Received 23 July 2016; Revised 29 September 2016; Accepted 10 October 2016 Academic Editor: Dimitris Georgopoulos Copyright © 2016 Macario Camacho et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Objective. To systematically review the international literature for studies evaluating internal (NoZovent) and external (Breathe Right Strips) nasal dilators as treatment for obstructive sleep apnea (OSA). Study Design. Systematic review with meta-analysis. Methods. Four databases, including PubMed/MEDLINE, were searched through September 29, 2016. Results. One-hundred twelve studies were screened, fifty-eight studies were reviewed, and fourteen studies met criteria. In 147 patients, the apnea-hypopnea index (AHI) was reported, and there was an improvement from a mean ± standard deviation (M ± SD) of 28.7±24.0 to 27.4±23.3 events/hr, 𝑝 value 0.64. There was no significant change in AHI, lowest oxygen saturation, or snoring index in OSA patients when using nasal dilators. However, a subanalysis demonstrated a slight reduction in apnea index (AI) with internal nasal dilators (decrease by 4.87 events/hr) versus minimal change for external nasal dilators (increase by 0.64 events/hr). Conclusion. Although nasal dilators have demonstrated improved nasal breathing, they have not shown improvement in obstructive sleep apnea outcomes, with the exception of mild improvement in apnea index when internal nasal dilators were used. 1. Introduction The nose is composed of both internal and external structures. Although the internal structures of the nose (i.e., turbinates [1], septum [2]) do not generally move in a dynamic fashion, they can become edematous with associated symptoms of congestion and obstruction. It is known that the nose may contribute to snoring [3] and obstructive sleep apnea (OSA) when congested or obstructed. There are many treatments for OSA, to include medical management with positive airway pressure devices [4], oral appliances, and myofunctional therapy [5]. Nasal therapies to help treat OSA include nasopharyngeal airway stenting devices [6], nasal expiratory positive airway pressure devices (Provent) [7], and nasal surgery [8, 9]. The simple act of changing from the upright to the supine position has been shown to reduce upper airway volume by approximately 33% in OSA patients [10]. Given that the nasal cavity is upstream from the collapsible soft tissues of the upper airway, the nasal cavity directly influences the downstream airflow. Moreover, when the nasal cavity’s crosssectional area increases by 10%, there is a corresponding 21% increase in nasal airflow [11]. Internal (NoZovent) and external (Breathe Right Strips) nasal dilators have been studied in the treatment of OSA for over twenty years, but to date there are no published 2 Pulmonary Medicine Table 1: General characteristics and quality criteria of included studies. Quality assessment of case series studies checklist from National Institute for Health and Clinical Excellence (NICE). (1) Was the case series collected in more than one center, that is, multicenter study? (2) Is the hypothesis/aim/objective of the study clearly described? (3) Are the inclusion and exclusion criteria (case definition) clearly reported? (4) Is there a clear definition of the outcomes reported? (5) Were data collected prospectively? (6) Is there an explicit statement that patients were recruited consecutively? (7) Are the main findings of the study clearly described? (8) Are outcomes stratified (e.g., by abnormal results, disease stage, and patient characteristics)? Amaro et al., 2012 Bahammam et al., 1999 Djupesland et al., 2001 Gosepath et al., 1999 Hoffstein et al., 1993 Hoijer et al., 1992 Kerr et al., 1992 Liistro et al., 1998 Metes et al., 1992 Pevernagie et al., 2000 Redline et al. 1998 Schonhofer et al., 2000 Todorova et al., 1998 Wenzel et al., 1997 (1) No No No No No No No No No No No No No No (2) Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes (3) Yes Yes No No No Yes No No No Yes Yes Yes Yes Yes meta-analyses of these interventions. Therefore, the objective of this study was to systematically review the international literature, without regard to language, for studies evaluating the pretreatment and treatment data of both internal and external nasal dilators as treatment for OSA and to then use the data to perform a meta-analysis. 2. Methods Three authors (M. C., O. O., and M. R.) independently searched PubMed/MEDLINE, Scopus, Embase, Google Scholar, and The Cochrane Library for studies, through September 29, 2016. 2.1. Search Strategy. Specific phrases, keywords, and MeSH terms were tailored to each database as appropriate. An example of a search strategy used in PubMed/MEDLINE includes (((“instrumentation” [Subheading]) AND (“Nasal Obstruction” [Mesh])) AND “Sleep Apnea Syndromes”) OR ((“Dilatation” [Mesh] AND (“instrumentation” [Subheading])) AND (((“Sleep Apnea, Obstructive” [Mesh]) OR (“Snoring” [Mesh]) AND “Dilatation” [Mesh])) AND (“Nasal Obstruction” [Mesh])) OR ((nasal dilator [tiab]) AND ((sleep apnea [All Fields] OR (sleep apnoea [All Fields]))) OR (nasal dilatation∗ AND sleep apnea∗ ) OR (nasal dilatation∗ AND snoring∗ )). 2.2. Study Selection. The inclusion criteria were as follows: (1) patients: adults ≥18 years old who have OSA, (2) intervention: nasal dilators, (3) comparison: sleep study data pretreatment and treatment, (4) outcome: sleep study parameters including apnea-hypopnea index (AHI), apnea index (AI), oxygen saturations, and sleepiness, and (5) study designs: all designs and all languages. (4) Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No (5) Yes Yes Yes No Yes Yes Yes Yes Yes Ye (...truncated)