EMST Shows Promise in Treating Moderate OSAS
In this expert Q&A, Nurel Ertürk, PhD, Tarsus University, Mersin Province, Turkey, discusses her study, “Expiratory muscle strength training reduces oxidative stress and systemic inflammation in men with obstructive sleep apnea syndrome: a double-blinded, randomized parallel trial,” which explored the impact of expiratory muscle strength training (EMST) on patients with obstructive sleep apnea syndrome (OSAS). Dr Ertürk discusses the study’s key findings related to systemic inflammation, oxidative stress, and sleep parameters, and offers insight on how EMST may be used in conjunction with traditional treatments to most effectively improve patient outcomes.
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Editors' note: This interview has been lightly edited for clarity.
Pulmonology Learning Network: Could you give us a brief overview of the study subject, design, and most significant findings?
Nurel Ertürk, PhD: Obstructive sleep apnea syndrome (OSAS) is a respiratory sleep disorder characterized by arousal from sleep or decreased oxygen saturation associated with apnea and hypopnea in the upper respiratory tract. Intermittent hypoxemia and reoxygenation result in the production of reactive oxygen species (ROS) and lead to the development of biomarkers associated with systemic inflammation. In particular, respiratory muscle strength training and multifunctional therapies are effective, portable, and basic treatment modality in patients with moderate OSAS. There are two options for respiratory muscle training. Expiratory muscle strength training (EMST) is one of them. Our study investigated the effects of EMST on OSAS patients, particularly its impact on systemic inflammation, oxidative stress, and overall sleep parameters. The study followed a randomized controlled design, with participants allocated into an EMST intervention group and a control group receiving standard care. The most significant findings indicated that EMST improved respiratory muscle strength, reduced disease severity measured by the Apnea Hypopnea İndex (AHI) and systemic inflammatory markers (TNF-a, IL-6), and decreased oxidative stress.
PLN: How do the effects of EMST compare to traditional treatments for OSAS, such as continuous positive airway pressure (CPAP) therapy, particularly in terms of reducing systemic inflammation and oxidative stress?
Ertürk: While CPAP remains the gold standard for OSAS management by maintaining airway patency, it does not directly address neuromuscular dysfunction or respiratory muscle weakness. EMST appears to have additional benefits, such as improving respiratory muscle strength and reducing inflammation and oxidative stress. However, EMST alone is not a substitute for CPAP in severe OSAS cases but may serve as a complementary therapy in moderate cases or in patients who are CPAP-intolerant.
PLN: What patient selection criteria would you recommend for clinicians considering EMST as a therapeutic option for their patients with moderate OSAS?
Ertürk: We selected patients with moderate OSAS who were unable or unwilling to use CPAP. It is important to ensure that hypertension and diabetes are under control. Patients with mild OSAS who have evidence of pharyngeal muscle weakness or expiratory muscle dysfunction, and those with OSAS-related light daytime sleepiness, snoring, and fatigue may also be eligible for this study.
PLN: Given that EMST was performed at home, what strategies did you employ to ensure patient adherence to the training protocol, and how might these be applied in routine clinical practice?
Ertürk: To maximize patient adherence, we implemented a structured training program prior to the initiation of the treatment. We conducted biweekly check-up calls to assess progress and address any challenges. During these check-ups, we inquired about symptoms, device adherence, potential adverse events, and made necessary adjustments to the respiratory muscle strength device to accommodate the increased workload. Additionally, we monitored patients' daily training adherence through the use of a treatment diary. These strategies can be applied in clinical settings by incorporating digital tools, periodic follow-ups, and patient engagement techniques.
PLN: Based on your research, what are the next steps or future studies needed to further understand the role of EMST in the management of OSAS, and how can neurologists contribute to this evolving field?
Ertürk: Further research should explore:
- The long-term effects of EMST on cardiovascular and neurocognitive outcomes in OSAS;
- Optimal training intensity and duration for sustained benefits;
- Combination therapies integrating EMST with myofunctional therapy or neurostimulation techniques;
- And the impact of EMST on central sleep apnea cases.
Neurologists can make treatment recommendations to patients with OSAS by considering holistic treatment strategies. They can contribute by observing the cognitive and neuromuscular effects of rehabilitation methods used to treat the multifactorial symptoms of OSAS.
Nurel Ertürk, PhD, is an assistant professor and vice chair of the Department of Physiotherapy and Rehabilitation at Tarsus University, specializing in cardiopulmonary rehabilitation and respiratory therapy. Dr Ertürk focuses on research related to Obstructive Sleep Apnea Syndrome (OSAS) and heart failure. Her research includes studies on the effects of inspiratory and expiratory muscle strength training in patients with OSAS. Her project investigating the effects of high- and low-intensity expiratory muscle strengthening training on OSAS patients was supported by the Scientific and Technological Research Council of Türkiye. Dr Ertürk also contributed to several national and international projects, making significant contributions to the fields of respiratory diseases and cardiopulmonary rehabilitation. Dr Ertürk has received numerous awards, including the Young Scientist Sponsorship and Science Incentive Awards from the European Respiratory Society (ERS) in 2012 and 2013. She has worked in both clinical and academic settings, and has delivered training on topics related to cardiovascular rehabilitation and ICU recovery.
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