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Volume 15 No. 06
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Accepted Papers

Scientific Investigations

The Effect of Upper Airway Surgery on Loop Gain in Obstructive Sleep Apnea

Yanru Li, MD1,2,3; Jingying Ye, MD1,2,4; Demin Han, MD1,2; Di Zhao, MD1,2; Xin Cao, MD1,2,4; Jeremy Orr, MD3; Rachel Jen, MD3; Naomi Deacon-Diaz, PhD3; Scott A. Sands, PhD5; Robert Owens, MD3; Atul Malhotra, MD3
1Department of Otolaryngology Head and Neck Surgery and Clinical Center for OSAHS, Beijing Tongren Hospital, Capital Medical University, Beijing, China; 2Key Laboratory of Otolaryngology Head and Neck Surgery (Ministry of Education of China), Capital Medical University, Beijing, China; 3Division of Pulmonary, Critical Care and Sleep Medicine, University of California, San Diego, San Diego, California; 4Department of Otolaryngology Head and Neck Surgery, Beijing Tsinghua Changgung Hospital, Beijing, China; 5Division of Sleep Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts

Study Objectives:

Controversy exists as to whether elevated loop gain is a cause or consequence of obstructive sleep apnea (OSA). Upper airway surgery is commonly performed in Asian patients with OSA who have failed positive airway pressure therapy and who are thought to have anatomical predisposition to OSA. We hypothesized that high loop gain would decrease following surgical treatment of OSA due to reduced sleep apnea severity.


Polysomnography was performed preoperatively and postoperatively to assess OSA severity in 30 Chinese participants who underwent upper airway surgery. Loop gain was calculated using a validated clinically-applicable method by fitting a feedback control model to airflow.


Patients were followed up for a median (interquartile range) of 130 (62, 224) days after surgery. Apnea-hypopnea index (AHI) changed from 60.8 (33.7, 71.7) to 18.4 (9.9, 42.5) events/h (P < .001). Preoperative and postoperative loop gain was 0.70 (0.58, 0.80) and 0.53 (0.46, 0.63) respectively (P < .001). There was a positive association between the decrease in loop gain and the improvement of AHI (P = .025).


High loop gain was reduced by surgical treatment of OSA in our cohort. These data suggest that elevated loop gain may be acquired in OSA and may provide mechanistic insight into improvement in OSA with upper airway surgery.

Clinical Trial Registration:

Registry:, Title: The Impact of Sleep Apnea Treatment on Physiology Traits in Chinese Patients With Obstructive Sleep Apnea, Identifier: NCT02696629, URL:


Li Y, Ye J, Han D, Zhao D, Cao X, Orr J, Jen R, Deacon-Diaz N, Sands SA, Owens R, Malhotra A. The effect of upper airway surgery on loop gain in obstructive sleep apnea. J Clin Sleep Med. 2019;15(6):907–913.

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