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Coppola S, Radovanovic D, Pozzi T, Danzo F, Rocco C, Lazzaroni G, Santus P, Chiumello D. Non-invasive respiratory support in elderly hospitalized patients. Expert Rev Respir Med 2024; 18:789-804. [PMID: 39267448 DOI: 10.1080/17476348.2024.2404696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Revised: 09/01/2024] [Accepted: 09/11/2024] [Indexed: 09/17/2024]
Abstract
INTRODUCTION The proportion of elderly people among hospitalized patients is rapidly growing. Between 7% to 25% of ICU patients are aged 85 and over and noninvasive respiratory support is often offered to avoid the risks of invasive mechanical ventilation or in patients with a 'do-not-intubate' order. However, while noninvasive respiratory support has been extensively studied in the general population, there is limited data available on its efficacy in elderly patients with ARF. AREAS COVERED PubMed/Medline, Web of Science, Scopus and Embase online databases were searched for studies that assessed clinical efficacy of high flow nasal cannula, continuous positive airway pressure and noninvasive ventilation in patients ≥ 65 years old with acute de novo ARF, showing that short to mid-term benefits provided by noninvasive respiratory support in elderly patients in terms of reduction of mechanical ventilation risk and mortality are similar to younger patients, if adjusted for the severity of comorbidities and respiratory failure. EXPERT OPINION Noninvasive support strategies can represent an effective opportunity in elderly patients with ARF, especially in patients too frail to undergo endotracheal intubation and in whom received or decided for a 'do not intubate' order. Indeed, noninvasive support has a different impact, depending on the setting.
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Affiliation(s)
- Silvia Coppola
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital Milan, Milan, Italy
| | - Dejan Radovanovic
- Division of Respiratory Diseases, Ospedale Luigi Sacco, Polo Universitario, ASST Fatebenefratelli-Sacco, Milan, Italy
- Department of Biomedical and Clinical Sciences (DIBIC), University of Milan, Milan, Italy
| | - Tommaso Pozzi
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Fiammetta Danzo
- Division of Respiratory Diseases, Ospedale Luigi Sacco, Polo Universitario, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Cosmo Rocco
- Department of Health Sciences, University of Milan, Milan, Italy
| | - Giada Lazzaroni
- Division of Respiratory Diseases, Ospedale Luigi Sacco, Polo Universitario, ASST Fatebenefratelli-Sacco, Milan, Italy
| | - Pierachille Santus
- Division of Respiratory Diseases, Ospedale Luigi Sacco, Polo Universitario, ASST Fatebenefratelli-Sacco, Milan, Italy
- Department of Biomedical and Clinical Sciences (DIBIC), University of Milan, Milan, Italy
| | - Davide Chiumello
- Department of Anesthesia and Intensive Care, ASST Santi Paolo e Carlo, San Paolo University Hospital Milan, Milan, Italy
- Department of Health Sciences, University of Milan, Milan, Italy
- Coordinated Research Center on Respiratory Failure, University of Milan, Milan, Italy
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Zhang R, Bai L, Han X, Huang S, Zhou L, Duan J. Incidence, characteristics, and outcomes of delirium in patients with noninvasive ventilation: a prospective observational study. BMC Pulm Med 2021; 21:157. [PMID: 33975566 PMCID: PMC8111378 DOI: 10.1186/s12890-021-01517-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 04/28/2021] [Indexed: 01/09/2023] Open
Abstract
Background Factors that may increase the risk for delirium and the firm knowledge around mechanism for delirium in noninvasive ventilation (NIV) patients is lacking. We investigated the incidence, characteristics, and outcomes of delirium in NIV patients. Methods A prospective observational study was performed in an intensive care unit (ICU) of a teaching hospital. Patients in whom NIV was used as a first-line intervention were enrolled. During NIV intervention, delirium was screened using the Confusion Assessment Method for the ICU each day. The association between delirium and poor outcomes (e.g., NIV failure, ICU and hospital mortality) was investigated using forward stepwise multivariate logistic regression analyses. Results We enrolled 1083 patients. Of these, 196 patients (18.1%) experienced delirium during NIV intervention. Patients with delirium had higher NIV failure rates (37.8% vs. 21.0%, p < 0.01), higher ICU mortality (33.2% vs. 14.3%, p < 0.01), and higher hospital mortality (37.2% vs. 17.0%, p < 0.01) than subjects without delirium. They also had a longer duration of NIV (median 6.3 vs. 3.7 days, p < 0.01), and stayed longer in the ICU (median 9.0 vs. 6.0 days, p < 0.01) and the hospital (median 14.5 vs. 11.0 days, p < 0.01). These results were confirmed in COPD and non-COPD cohorts. According to subtype, compared to hyperactive delirium patients, hypoactive and mixed delirium patients spent more days and many more days on NIV (median 3.4 vs. 6.5 vs. 10.1 days, p < 0.01). Similar outcomes were found for length of stay in the ICU and hospital. However, NIV failure, ICU mortality, and hospital mortality did not differ among the three subtypes. Conclusions Delirium is associated with increases in poor outcomes (NIV failure, ICU mortality, and hospital mortality) and the use of medical resources (duration of NIV, and lengths of stay in the ICU and hospital). Regarding subtype, hypoactive and mixed delirium are associated with higher, and much higher, consumption of medical resources, respectively, compared to hyperactive delirium. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-021-01517-3.
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Affiliation(s)
- Rui Zhang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, China
| | - Linfu Bai
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, China
| | - Xiaoli Han
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, China
| | - Shicong Huang
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, China
| | - Lintong Zhou
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, China
| | - Jun Duan
- Department of Respiratory and Critical Care Medicine, The First Affiliated Hospital of Chongqing Medical University, Youyi Road 1, Yuzhong District, Chongqing, 400016, China.
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Peko Cohen L, Gefen A. Phantom testing of the sensitivity and precision of a sub-epidermal moisture scanner. Int Wound J 2019; 16:979-988. [PMID: 30989825 DOI: 10.1111/iwj.13132] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 03/26/2019] [Accepted: 03/30/2019] [Indexed: 12/30/2022] Open
Abstract
The majority of pressure ulcers (PUs) including deep tissue injuries (DTIs) are preventable, and even reversible if detected in their early phase. One of the greatest barriers in PU prevention is that clinicians traditionally depended on subjective and qualitative techniques, particularly routine visual skin assessments that would only document existing, macroscopic PUs/DTIs, rather than preventing them or detecting them at their microscopic phase. At the early phase of cell damage, when a forming PU is still microscopic, there is a local increase in extracellular fluid contents within affected tissues, which is called sub-epidermal moisture (SEM). This new understanding has led to an emerging technology, a SEM Scanner (BBI LLC, Bruin Biometrics) that has been designed to effectively examine the health status of tissues, by measuring local changes in the biophysical SEM marker. In the present work, the SEM Scanner was tested under controlled laboratory conditions to experimentally determine its sensitivity and precision in identifying small (1 mL) water content changes in phantoms of the human heel and skull/face, which simulated common PU development scenarios. In both phantom configurations, the locally increased water contents resulted in consistent, statistically significant elevated SEM readings, which confirms that the SEM Scanner is able to detect fluid content changes that are as small as 1 mL. In agreement with a simplified theoretical (mathematical) SEM model, which was also developed here, changes in water contents had a consistent trend of effect on SEM delta values, which increased with each 1 mL increment in intra-tissue-substitute water contents.
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Affiliation(s)
- Lea Peko Cohen
- Department of Biomedical Engineering, Faculty of Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Amit Gefen
- Department of Biomedical Engineering, Faculty of Engineering, Tel Aviv University, Tel Aviv, Israel
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Peko Cohen L, Ovadia-Blechman Z, Hoffer O, Gefen A. Dressings cut to shape alleviate facial tissue loads while using an oxygen mask. Int Wound J 2019; 16:813-826. [PMID: 30838792 DOI: 10.1111/iwj.13101] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 01/27/2019] [Accepted: 02/04/2019] [Indexed: 11/28/2022] Open
Abstract
Non-invasive ventilation (NIV) masks are commonly used for respiratory support where intubation or a surgical procedure can be avoided. However, prolonged use of NIV masks involves risk to facial tissues, which are subjected to sustained deformations caused by tightening of the mask and microclimate conditions. The risk of developing such medical device-related pressure ulcers can be reduced by providing additional cushioning at the mask-face interface. In this work, we determined differences in facial tissue stresses while using an NIV mask with versus without using dressing cuts (Mepilex Lite; Mölnlycke Health Care, Gothenburg, Sweden). First, we developed a force measurement system that was used to experimentally determine local forces applied to skin at the bridge of the nose, cheeks, and chin in a healthy sample group while using a NIV mask. We further demonstrated facial temperature distributions after use of the mask using infrared thermography. Next, using the finite element method, we delivered the measured compressive forces per site of the face in the model and compared maximal effective stresses in facial tissues with versus without the dressing cuts. The dressings have shown substantial biomechanical effectiveness in alleviating facial tissues deformations and stresses by providing localised cushioning to the tissues at risk.
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Affiliation(s)
- Lea Peko Cohen
- Department of Biomedical Engineering, Faculty of Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Zehava Ovadia-Blechman
- Department of Medical Engineering, Afeka Tel Aviv Academic College of Engineering, Tel Aviv, Israel
| | - Oshrit Hoffer
- Department of Medical Engineering, Afeka Tel Aviv Academic College of Engineering, Tel Aviv, Israel
| | - Amit Gefen
- Department of Biomedical Engineering, Faculty of Engineering, Tel Aviv University, Tel Aviv, Israel
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Outcome of older persons admitted to intensive care unit, mortality, prognosis factors, dependency scores and ability trajectory within 1 year: a prospective cohort study. Aging Clin Exp Res 2018; 30:1041-1051. [PMID: 29214518 DOI: 10.1007/s40520-017-0871-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2017] [Accepted: 11/28/2017] [Indexed: 02/04/2023]
Abstract
BACKGROUND The outcome and functional trajectory of older persons admitted to intensive care (ICU) unit remain a true question for critical care physicians and geriatricians, due to the heterogeneity of geriatric population, heterogeneity of practices and absence of guidelines. AIM To describe the 1-year outcome, prognosis factors and functional trajectory for older people admitted to ICU. METHODS In a prospective 1-year cohort study, all patients aged 75 years and over admitted to our ICU were included according to a global comprehensive geriatric assessment. Follow-up was conducted for 1 year survivors, in particular, ability scores and living conditions. RESULTS Of 188 patients included [aged 82.3 ± 4.7 years, 46% of admissions, median SAPS II 53.5 (43-74), ADL of Katz's score 4.2 ± 1.6, median Barthel's index 71 (55-90), AGGIR scale 4.5 ± 1.5], the ICU, hospital and 1-year mortality were, respectively, 34, 42.5 and 65.5%. Prognosis factors were: SAPS 2, mechanical ventilation, comorbidity (Lee's and Mc Cabe's scores), disability scores (ADL of Katz's score, Barthel's index and AGGIR scale), admission creatinin, hypoalbuminemia, malignant haemopathy, cognitive impairment. One-year survivors lived in their own home for 83%, with a preserved physical ability, without significant variation of the three ability assessed scores compared to prior ICU admission. CONCLUSION The mortality of older people admitted to ICU is high, with a significant impact of disabilty scores, and preserved 1-year survivor independency. Other studies, including a better comprehensive geriatric assessment, seem necessary to determine a predictive "phenotype" of survival with a "satisfactory" level of autonomy.
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Vargas N, Vargas M, Galluccio V, Carifi S, Villani C, Trasente V, Landi CAE, Cirocco A, Di Grezia F. Non-invasive ventilation for very old patients with limitations to respiratory care in half-open geriatric ward: experience on a consecutive cohort of patients. Aging Clin Exp Res 2014; 26:615-23. [PMID: 24781827 DOI: 10.1007/s40520-014-0223-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2013] [Accepted: 04/08/2014] [Indexed: 10/25/2022]
Abstract
INTRODUCTION A leading role for non-invasive ventilation (NIV), as comfort treatment or palliative care, is actually recognized for very old patients suffering from ARF. NIV was frequently used in both ICU and respiratory ICU (RICUs) for very old patients and it is associated with a reduced rate of endotracheal intubations and mortality. This study aims to evaluate the effects of NIV, performed in a setting of half-open geriatric ward with family support, in a cohort of very old patients with ARF and DNI decision. METHODS A consecutive cohort of 20 very old patients with DNI decision was admitted in our 26-bed geriatric ward during a 6 months' period. DNI decision was obtained in emergency room with an intensive care physician supported by a psychologist. Pressure support ventilation was the first choice of NIV. NIV has been performed by three adequately trained geriatricians, with one of them experienced in ICU, and in close collaboration with intensive care physicians. Arterial blood gases, to assess the response to ventilation, were obtained after 1, 6 and 12 h. NIV settings were modified according to arterial blood gas analyses or respiratory fatigue, if needed. RESULTS Therefore, 75% of patients were discharged home and 12 out of 20 patients had home respiratory support. PaO2/FiO2 ratio and pH increased while PaCO2 decreased during the 12 h of NIV with statistical significance. At the admission, alive patients had PaCO2 significantly lower than dead patients. After 12 h, alive patients had a better pH than dead patients. Dead patients experienced more complication than survivors. CONCLUSION Very old DNI patients with ARF could be treated with NIV in half-open geriatric ward with trained physicians and nurses. The presence of family members may improve patients' comfort and reduce anxiety level even at the end of life. Further studies are needed to address the effective role of NIV in very old patients with DNI decisions.
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Noninvasive positive pressure ventilation for acute respiratory failure in delirious patients: understudied, underreported, or underappreciated? A systematic review and meta-analysis. Lung 2012; 190:597-603. [PMID: 22782122 DOI: 10.1007/s00408-012-9403-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2012] [Accepted: 06/15/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND We performed a systematic review and meta-analysis of the literature to determine the prevalence of delirium in patients receiving noninvasive positive pressure ventilation (NPPV) for acute respiratory failure and to quantify the prognostic impact of delirium with respect to NPPV failure. METHOD We searched the databases EMBASE (1996 to present), MEDLINE (1996 to present), PsycINFO(®) (2002 to present) and CINAHL (1992 to present). A Google™ search and hand searching of bibliographies or relevant articles were also performed. We searched for prospective observational studies conducted in a setting where patients with acute respiratory failure receiving NPPV were screened for delirium. All authors independently assessed references for inclusion and extracted data. Information was collated regarding study design, baseline characteristics of included patients, and the prevalence of delirium. Where prognostic information regarding NPPV failure was reported, a risk ratio for the association between delirium and NPPV failure was derived. These values were pooled in the meta-analysis. RESULTS Three articles were retrieved by the search strategy. These included 239 patients receiving noninvasive ventilation who were assessed for delirium. The prevalence of delirium was recorded at between 33 and 38 % with a pooled prevalence of 37 %. Two studies reported prognostic data and the risk ratios for noninvasive ventilation failure in delirium were calculated as 1.79 (95 % CI 1.09-2.94) and 3.28 (95 % CI 1.60-6.73). A meta-analysis was performed and the pooled risk ratio was found to be 2.12 (95 % CI 1.41-3.18). CONCLUSIONS The data in this context was scarce and of low quality. A diagnosis of delirium was made in 9 patients and inferred in 80. Despite the current lack of high-quality data and studies, the high reported prevalence of delirium and the association with noninvasive ventilation failure lends support for more awareness amongst health-care professionals and more routine screening. More focused primary research is necessary in this area. Adherence to NICE guidelines regarding delirium in these patients should be a standard of care.
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Nazir SA, Erbland ML. Chronic obstructive pulmonary disease: an update on diagnosis and management issues in older adults. Drugs Aging 2010; 26:813-31. [PMID: 19761275 DOI: 10.2165/11316760-000000000-00000] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Chronic obstructive pulmonary disease (COPD) is a debilitating disease of the elderly that causes significant morbidity and mortality. Despite being a treatable and preventable disease, the prevalence continues to rise because of the worldwide epidemic of smoking. COPD is associated with enormous healthcare costs. It has systemic effects, and common co-morbid conditions such as cardiovascular disease, muscle wasting and osteoporosis may all be linked through a common systemic inflammatory cascade. Depression, anxiety and malnutrition are also common in elderly COPD patients. These factors not only affect quality of life (QOL) but also compliance with therapy. Malnutrition is an independent predictor of mortality and poor outcome. Spirometry is essential for the diagnosis of COPD, but the criteria defining airflow limitation are not clear cut for elderly patients and could result in over-diagnosis. However, older patients perceive their symptoms differently, and COPD could also be under-diagnosed in this population. Acute exacerbations result in worsening symptoms that necessitate additional treatment, and may cause a more rapid decline in lung function and QOL. The management of elderly patients with COPD should encompass a multidisciplinary approach. An evaluation of patients' nutritional status and mental health should be undertaken, in addition to assessing their lung function and functional impairment. Significant underlying co-morbidities should be evaluated and treated to derive the maximal benefit of therapy. Specific therapy for COPD should start with cessation of exposure to the most important risk factor, tobacco smoke. Smoking cessation rates in the elderly have not declined, and this may reflect an underlying reluctance by physicians to counsel and offer smoking cessation therapies to the elderly. Unlike oxygen therapy in hypoxaemic patients, bronchodilators and corticosteroids do not decrease mortality in COPD patients and they are primarily directed towards symptom relief. However, they do have a positive effect on QOL and exacerbation rates. The choice of delivery devices for inhaled medications is important in the elderly, and patients' inhaler technique and manual dexterity should be frequently assessed. Pulmonary rehabilitation and nutritional supplementation are other important components of care. End-of-life issues should be adequately addressed in the elderly with COPD, and an approach integrating curative and palliative interventions is recommended.
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Affiliation(s)
- Shoab A Nazir
- Division of Pulmonary and Critical Care Medicine, University of Arkansas for Medical Sciences, and Central Arkansas Veterans Health Care System, Little Rock, Arkansas, USA.
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Thain GS, Duncan N, Rosie G, Currie GP, Christie GL. Real-life experience of older patients requiring non-invasive ventilation for exacerbations of chronic obstructive pulmonary disease. Respir Med 2009; 103:941-2. [PMID: 19286362 DOI: 10.1016/j.rmed.2009.01.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2008] [Accepted: 01/05/2009] [Indexed: 11/30/2022]
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The effect of protective treatment in reducing pressure ulcers for non-invasive ventilation patients. Intensive Crit Care Nurs 2008; 24:295-9. [DOI: 10.1016/j.iccn.2007.11.005] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2007] [Revised: 11/06/2007] [Accepted: 11/28/2007] [Indexed: 11/22/2022]
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Lunghar L, D'Ambrosio CM. Noninvasive ventilation in the older patient who has acute respiratory failure. Clin Chest Med 2008; 28:793-800, vii. [PMID: 17967295 DOI: 10.1016/j.ccm.2007.08.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Older patients are at significantly increased risk of acute respiratory failure from multiple causes. Noninvasive positive pressure ventilation has been shown to dramatically improve care of patients with acute respiratory failure. Patient selection is important in all patients being treated with noninvasive positive pressure ventilation but is especially important in older patients. Delirium, confusion, and dementia can lead to difficulty for patients in tolerating this procedure and lead to a worsening respiratory status. The presence of a do-not-intubate order does not necessarily preclude the use of noninvasive positive pressure ventilation, and some patients may derive significant benefit from its use. Overall, noninvasive positive pressure ventilation is a reasonable and justifiable option in the treatment of acute respiratory failure in older patients.
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Affiliation(s)
- Layola Lunghar
- Pulmonary, Critical Care and Sleep Medicine Division, The Center for Sleep Medicine, Tufts University School of Medicine, Tufts-New England Medical Center, 750 Washington Street #257, Boston, MA 02111, USA
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