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Baniak LM, Orbell SL, Luyster FS, Henker R, Strollo PJ. Perioperative management of obstructive sleep apnea in lower extremity orthopedic procedures: A review of evidence to inform the development of a clinical pathway. Sleep Med Rev 2023; 67:101712. [PMID: 36442290 DOI: 10.1016/j.smrv.2022.101712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 10/14/2022] [Accepted: 10/30/2022] [Indexed: 11/11/2022]
Abstract
Obstructive sleep apnea (OSA) is unrecognized in as high as 80% of patients before surgery. When untreated, OSA increases a surgical patient's propensity for airway collapse and sleep deprivation lending to a higher risk for emergent re-intubation, prolonged recovery time, escalation of care, hospital readmission, and longer length of stay. We have reviewed the evidence regarding diagnostic performance of OSA screening methods and the impact of perioperative management strategies on postoperative complications among patients with diagnosed or suspected OSA who are undergoing orthopedic surgery. We then integrated the data and recommendations from professional society guidelines to develop an evidence-based clinical care pathway to optimize the perioperative management of this surgical population. Successful management of patients with diagnosed or suspected OSA encompass five facets of care: screening, education, airway management, medications, and monitoring. This narrative review revealed two gaps in the evidence to inform management of patients undergoing orthopedic surgery 1) during the perioperative setting to include evidence-based interventions that reduce postoperative complications and 2) after discharge to an unmonitored environment. The clinical care pathway as well as perspectives for future research are discussed.
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Affiliation(s)
- Lynn M Baniak
- Veteran Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA; School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA.
| | - Staci L Orbell
- School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
| | - Faith S Luyster
- School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
| | - Richard Henker
- School of Nursing, University of Pittsburgh, Pittsburgh, PA, USA
| | - Patrick J Strollo
- Veteran Affairs Pittsburgh Healthcare System, Pittsburgh, PA, USA; School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
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2
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Sarkar M, Madabhavi I, Kadakol N. Oxygen-induced hypercapnia: physiological mechanisms and clinical implications. Monaldi Arch Chest Dis 2022. [DOI: 10.4081/monaldi.2022.2399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 10/24/2022] [Indexed: 11/19/2022] Open
Abstract
Oxygen is probably the most commonly prescribed drug in the emergency setting and is a life-saving modality as well. However, like any other drug, oxygen therapy may also lead to various adverse effects. Patients with chronic obstructive pulmonary disease (COPD) may develop hypercapnia during supplemental oxygen therapy, particularly if uncontrolled. The risk of hypercapnia is not restricted to COPD only; it has also been reported in patients with morbid obesity, asthma, cystic fibrosis, chest wall skeletal deformities, bronchiectasis, chest wall deformities, or neuromuscular disorders. However, the risk of hypercapnia should not be a deterrent to oxygen therapy in hypoxemic patients with chronic lung diseases, as hypoxemia may lead to life-threatening cardiovascular complications. Various mechanisms leading to the development of oxygen-induced hypercapnia are the abolition of ‘hypoxic drive’, loss of hypoxic vasoconstriction and absorption atelectasis leading to an increase in dead-space ventilation and Haldane effect. The international guideline recommends a target oxygen saturation of 88% to 92% in patients with acute exacerbations of chronic obstructive pulmonary disease (AECOPD) and other chronic lung diseases at risk of hypercapnia. Oxygen should be administered only when oxygen saturation is below 88%. We searched PubMed, EMBASE, and the CINAHL from inception to June 2022. We used the following search terms: “Hypercapnia”, “Oxygen therapy in COPD”, “Oxygen-associated hypercapnia”, “oxygen therapy”, and “Hypoxic drive”. All types of study are selected. This review will focus on the physiological mechanisms of oxygen-induced hypercapnia and its clinical implications.
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Seet E, Waseem R, Chan MTV, Wang CY, Liao V, Suen C, Chung F. Characteristics of Patients with Unrecognized Sleep Apnea Requiring Postoperative Oxygen Therapy. J Pers Med 2022; 12:jpm12101543. [PMID: 36294683 PMCID: PMC9605207 DOI: 10.3390/jpm12101543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Revised: 09/08/2022] [Accepted: 09/16/2022] [Indexed: 11/26/2022] Open
Abstract
Surgical patients with obstructive sleep apnea (OSA) have increased risk of perioperative complications. The primary objective is to determine the characteristics of surgical patients with unrecognized OSA requiring oxygen therapy for postoperative hypoxemia. The secondary objective is to investigate the characteristics of patients who were responsive to oxygen therapy. This was a post-hoc multicenter study involving patients with cardiovascular risk factors undergoing major non-cardiac surgery. Patients ≥45 years old underwent Type 3 sleep apnea testing and nocturnal oximetry preoperatively. Responders to oxygen therapy were defined as individuals with ≥50% reduction in oxygen desaturation index (ODI) on postoperative night 1 versus preoperative ODI. In total, 624 out of 823 patients with unrecognized OSA required oxygen therapy. These were mostly males, had larger neck circumferences, higher Revised Cardiac Risk Indices, higher STOP-Bang scores, and higher ASA physical status, undergoing intraperitoneal or vascular surgery. Multivariable regression analysis showed that the preoperative longer cumulative time SpO2 < 90% or CT90% (adjusted p = 0.03), and lower average overnight SpO2 (adjusted p < 0.001), were independently associated with patients requiring oxygen therapy. Seventy percent of patients were responders to oxygen therapy with ≥50% ODI reduction. Preoperative ODI (19.0 ± 12.9 vs. 14.1 ± 11.4 events/h, p < 0.001), CT90% (42.3 ± 66.2 vs. 31.1 ± 57.0 min, p = 0.038), and CT80% (7.1 ± 22.6 vs. 3.6 ± 8.7 min, p = 0.007) were significantly higher in the responder than the non-responder. Patients with unrecognized OSA requiring postoperative oxygen therapy were males with larger neck circumferences and higher STOP-Bang scores. Those responding to oxygen therapy were likely to have severe OSA and worse preoperative nocturnal hypoxemia. Preoperative overnight oximetry parameters may help in stratifying patients.
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Affiliation(s)
- Edwin Seet
- Department of Anaesthesia, Yong Loo Lin School of Medicine, National University of Singapore, Singapore 117559, Singapore
- Department of Anaesthesia, Khoo Teck Puat Hospital, National Healthcare Group, Singapore 768828, Singapore
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore 637718, Singapore
- Correspondence:
| | - Rida Waseem
- Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON M5T 1R8, Canada
| | - Matthew T. V. Chan
- Department of Anaesthesia and Intensive Care, Chinese University of Hong Kong, Hong Kong SAR 999077, China
| | - Chew Yin Wang
- Department of Anaesthesiology, Faculty of Medicine, University of Malaya, Kuala Lumpur 50603, Malaysia
| | - Vanessa Liao
- Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON M5T 1R8, Canada
- University of Western Ontario, London, ON N6A 3K7, Canada
| | - Colin Suen
- Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON M5T 1R8, Canada
| | - Frances Chung
- Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON M5T 1R8, Canada
- University of Toronto, Toronto, ON M5S 3E5, Canada
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Li T, Zhou D, Zhao D, Lin Q, Wang D, Wang C, Zhang R. Impact of Oxygen Saturation on Mortality in Obese and Non-obese Critically Ill Patients With Mechanical Ventilation: A Retrospective Observational Study. Front Med (Lausanne) 2022; 9:839787. [PMID: 35492310 PMCID: PMC9051400 DOI: 10.3389/fmed.2022.839787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 03/25/2022] [Indexed: 11/17/2022] Open
Abstract
Background The main aim of this study was to evaluate the effect of oxygen saturation on mortality in critically ill patients with mechanical ventilation according to obesity status. Methods We conducted an observational study in mechanically ventilated patients admitted to the ICU retrospectively. Demographic, arterial blood gas, ventilator setting, interventions, and peripheral oxygen saturation (Spo2) during the first 24 h were recorded and analyzed between non-obese and obese patients. The main exposure included Spo2, time-weighted mean Spo2 (TWM-Spo2), and proportion of time spent in different Spo2 (PTS-Spo2) levels. The primary outcome was hospital mortality. We used multivariable logistic regression models to assess the relationship between Spo2 and mortality, as well as the interaction between PTS-Spo2 and obesity status. Results A total of 25,100 patients were included, of which 10,564 (42%) were obese patients. After adjusting for confounders, compared with TWM-Spo2 of 94–98%, TWM-Spo2 of < =88% (OR 3.572; CI [2.343, 5.455]; p < 0.001) and of 89–93% (OR 1.514; CI [1.343, 1.706]; p < 0.001) were both associated with higher risk of mortality. PTS-Spo2 of 99–100% was associated with increased risk of mortality for obese patients (OR 1.028; 95% CI 1.010–1.046; p = 0.002; Pinteraction = 0.001), while PTS-Spo2 of 89–93% was associated with increased risk of mortality (OR 1.089; 95% CI 1.051–1.128; p < 0.001; Pinteraction = 0.001) for non-obese patients. Conclusions For obese and non-obese critically ill patients with mechanical ventilation, the impact of oxygen saturation on hospital mortality is different.
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Barnett A, Beasley R, Buchan C, Chien J, Farah CS, King G, McDonald CF, Miller B, Munsif M, Psirides A, Reid L, Roberts M, Smallwood N, Smith S. Thoracic Society of Australia and New Zealand Position Statement on Acute Oxygen Use in Adults: 'Swimming between the flags'. Respirology 2022; 27:262-276. [PMID: 35178831 PMCID: PMC9303673 DOI: 10.1111/resp.14218] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 11/28/2021] [Accepted: 01/03/2022] [Indexed: 12/14/2022]
Abstract
Oxygen is a life-saving therapy but, when given inappropriately, may also be hazardous. Therefore, in the acute medical setting, oxygen should only be given as treatment for hypoxaemia and requires appropriate prescription, monitoring and review. This update to the Thoracic Society of Australia and New Zealand (TSANZ) guidance on acute oxygen therapy is a brief and practical resource for all healthcare workers involved with administering oxygen therapy to adults in the acute medical setting. It does not apply to intubated or paediatric patients. Recommendations are made in the following six clinical areas: assessment of hypoxaemia (including use of arterial blood gases); prescription of oxygen; peripheral oxygen saturation targets; delivery, including non-invasive ventilation and humidified high-flow nasal cannulae; the significance of high oxygen requirements; and acute hypercapnic respiratory failure. There are three sections which provide (1) a brief summary, (2) recommendations in detail with practice points and (3) a detailed explanation of the reasoning and evidence behind the recommendations. It is anticipated that these recommendations will be disseminated widely in structured programmes across Australia and New Zealand.
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Affiliation(s)
- Adrian Barnett
- Department of Respiratory and Sleep MedicineMater Public HospitalSouth BrisbaneQueenslandAustralia
| | - Richard Beasley
- Medical Research Institute of New Zealand & Capital Coast District Health BoardWellingtonNew Zealand
| | - Catherine Buchan
- Department of Respiratory and Sleep MedicineThe Alfred HospitalMelbourneVictoriaAustralia
- Department of Immunology and Respiratory MedicineMonash UniversityMelbourneVictoriaAustralia
| | - Jimmy Chien
- Department of Respiratory and Sleep MedicineWestmead Hospital, Ludwig Engel Centre for Respiratory Research and University of SydneySydneyNew South WalesAustralia
| | - Claude S. Farah
- Department of Respiratory Medicine, Concord HospitalMacquarie University and University of SydneySydneyNew South WalesAustralia
| | - Gregory King
- Department of Respiratory and Sleep Medicine, Royal North Shore HospitalWoolcock Institute of Medical Research and University of SydneySydneyNew South WalesAustralia
| | - Christine F. McDonald
- Department of Respiratory and Sleep MedicineAustin Health and University of MelbourneMelbourneVictoriaAustralia
| | - Belinda Miller
- Department of Respiratory MedicineThe Alfred Hospital and Monash UniversityMelbourneVictoriaAustralia
| | - Maitri Munsif
- Department of Respiratory and Sleep MedicineAustin Health and University of MelbourneMelbourneVictoriaAustralia
| | - Alex Psirides
- Intensive Care UnitWellington Regional Hospital, Capital and Coast District Health BoardWellingtonNew Zealand
| | - Lynette Reid
- Respiratory MedicineRoyal Hobart HospitalHobartTasmaniaAustralia
| | - Mary Roberts
- Department of Respiratory and Sleep MedicineWestmead Hospital, Ludwig Engel Centre for Respiratory Research and University of SydneySydneyNew South WalesAustralia
| | - Natasha Smallwood
- Department of Respiratory and Sleep MedicineThe Alfred HospitalMelbourneVictoriaAustralia
- Department of Immunology and Respiratory MedicineMonash UniversityMelbourneVictoriaAustralia
| | - Sheree Smith
- School of Nursing and MidwiferyWestern Sydney UniversitySydneyNew South WalesAustralia
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Gottlieb J, Capetian P, Hamsen U, Janssens U, Karagiannidis C, Kluge S, Nothacker M, Roiter S, Volk T, Worth H, Fühner T. German S3 Guideline: Oxygen Therapy in the Acute Care of Adult Patients. Respiration 2021; 101:214-252. [PMID: 34933311 DOI: 10.1159/000520294] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 10/06/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Oxygen (O2) is a drug with specific biochemical and physiological properties, a range of effective doses and may have side effects. In 2015, 14% of over 55,000 hospital patients in the UK were using oxygen. 42% of patients received this supplemental oxygen without a valid prescription. Health care professionals are frequently uncertain about the relevance of hypoxemia and have low awareness about the risks of hyperoxemia. Numerous randomized controlled trials about targets of oxygen therapy have been published in recent years. A national guideline is urgently needed. METHODS A national S3 guideline was developed and published within the Program for National Disease Management Guidelines (AWMF) with participation of 10 medical associations. A literature search was performed until February 1, 2021, to answer 10 key questions. The Oxford Centre for Evidence-Based Medicine (CEBM) System ("The Oxford 2011 Levels of Evidence") was used to classify types of studies in terms of validity. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used for assessing the quality of evidence and for grading guideline recommendation, and a formal consensus-building process was performed. RESULTS The guideline includes 34 evidence-based recommendations about indications, prescription, monitoring and discontinuation of oxygen therapy in acute care. The main indication for O2 therapy is hypoxemia. In acute care both hypoxemia and hyperoxemia should be avoided. Hyperoxemia also seems to be associated with increased mortality, especially in patients with hypercapnia. The guideline provides recommended target oxygen saturation for acute medicine without differentiating between diagnoses. Target ranges for oxygen saturation are based depending on ventilation status risk for hypercapnia. The guideline provides an overview of available oxygen delivery systems and includes recommendations for their selection based on patient safety and comfort. CONCLUSION This is the first national guideline on the use of oxygen in acute care. It addresses health care professionals using oxygen in acute out-of-hospital and in-hospital settings.
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Affiliation(s)
- Jens Gottlieb
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany.,Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany
| | - Philipp Capetian
- Department of Neurology, University Hospital Würzburg, Wuerzburg, Germany
| | - Uwe Hamsen
- Department of General and Trauma Surgery, BG University Hospital Bergmannsheil, Bochum, Germany
| | - Uwe Janssens
- Medical Clinic and Medical Intensive Care Medicine, St. Antonius Hospital, Eschweiler, Germany
| | - Christian Karagiannidis
- Department of Pneumology and Critical Care Medicine, Cologne-Merheim Hospital, ARDS and ECMO Centre, Kliniken der Stadt Köln, Witten/Herdecke University Hospital, Cologne, Germany
| | - Stefan Kluge
- University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Monika Nothacker
- AWMF-Institute for Medical Knowledge Management, Marburg, Germany
| | - Sabrina Roiter
- Intensive Care Unit, Israelite Hospital Hamburg, Hamburg, Germany
| | - Thomas Volk
- Department of Anesthesiology, University Hospital of Saarland, Saarland University, Homburg, Germany
| | | | - Thomas Fühner
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research (DZL), Hannover, Germany.,Department of Respiratory Medicine, Siloah Hospital, Hannover, Germany
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7
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Young PJ, Frei D. Oxygen therapy for critically Ill and post-operative patients. J Anesth 2021; 35:928-938. [PMID: 34490494 PMCID: PMC8420843 DOI: 10.1007/s00540-021-02996-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Accepted: 08/28/2021] [Indexed: 11/02/2022]
Abstract
Nearly all patients receiving treatment in a peri-operative or intensive care setting receive supplemental oxygen therapy. It is biologically plausible that the dose of oxygen used might affect important patient outcomes. Most peri-operative research has focussed on oxygen regimens that target higher than normal blood oxygen levels. Whereas, intensive care research has mostly focussed on conservative oxygen regimens which assiduously avoid exposure to higher than normal blood oxygen levels. While such conservative oxygen therapy is preferred for spontaneously breathing patients with chronic obstructive pulmonary disease, the optimal oxygen regimen in other patient groups is not clear. Some data suggest that conservative oxygen therapy might be preferred for patients with hypoxic ischaemic encephalopathy. However, unless oxygen supplies are constrained, routinely aggressively down-titrating oxygen in either the peri-operative or intensive care setting is not necessary based on available data. Targeting higher than normal levels of oxygen might reduce surgical site infections in the perioperative setting and/or improve outcomes for intensive care patients with sepsis but further research is required and available data are not sufficiently strong to warrant routine implementation of such oxygen strategies.
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Affiliation(s)
- Paul J Young
- Medical Research Institute of New Zealand, Private Bag 7902, Wellington, 6242, New Zealand. .,Intensive Care Unit, Wellington Regional Hospital, Wellington, New Zealand. .,Australian and New Zealand Intensive Care Research Centre, Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia. .,Department of Critical Care, University of Melbourne, Parkville, VIC, Australia.
| | - Daniel Frei
- Medical Research Institute of New Zealand, Private Bag 7902, Wellington, 6242, New Zealand.,Department of Anaesthesia, Wellington Regional Hospital, Wellington, New Zealand
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8
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Gottlieb J, Capetian P, Hamsen U, Janssens U, Karagiannidis C, Kluge S, König M, Markewitz A, Nothacker M, Roiter S, Unverzagt S, Veit W, Volk T, Witt C, Wildenauer R, Worth H, Fühner T. [German S3 Guideline - Oxygen Therapy in the Acute Care of Adult Patients]. Pneumologie 2021; 76:159-216. [PMID: 34474487 DOI: 10.1055/a-1554-2625] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Oxygen (O2) is a drug with specific biochemical and physiologic properties, a range of effective doses and may have side effects. In 2015, 14 % of over 55 000 hospital patients in the UK were using oxygen. 42 % of patients received this supplemental oxygen without a valid prescription. Healthcare professionals are frequently uncertain about the relevance of hypoxemia and have low awareness about the risks of hyperoxemia. Numerous randomized controlled trials about targets of oxygen therapy have been published in recent years. A national guideline is urgently needed. METHODS A S3-guideline was developed and published within the Program for National Disease Management Guidelines (AWMF) with participation of 10 medical associations. Literature search was performed until Feb 1st 2021 to answer 10 key questions. The Oxford Centre for Evidence-Based Medicine (CEBM) System ("The Oxford 2011 Levels of Evidence") was used to classify types of studies in terms of validity. Grading of Recommendations, Assessment, Development and Evaluation (GRADE) was used and for assessing the quality of evidence and for grading guideline recommendation and a formal consensus-building process was performed. RESULTS The guideline includes 34 evidence-based recommendations about indications, prescription, monitoring and discontinuation of oxygen therapy in acute care. The main indication for O2 therapy is hypoxemia. In acute care both hypoxemia and hyperoxemia should be avoided. Hyperoxemia also seems to be associated with increased mortality, especially in patients with hypercapnia. The guideline provides recommended target oxygen saturation for acute medicine without differentiating between diagnoses. Target ranges for oxygen saturation are depending on ventilation status risk for hypercapnia. The guideline provides an overview of available oxygen delivery systems and includes recommendations for their selection based on patient safety and comfort. CONCLUSION This is the first national guideline on the use of oxygen in acute care. It addresses healthcare professionals using oxygen in acute out-of-hospital and in-hospital settings. The guideline will be valid for 3 years until June 30, 2024.
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Affiliation(s)
- Jens Gottlieb
- Klinik für Pneumologie, Medizinische Hochschule Hannover.,Biomedical Research in End-stage and Obstructive Lung Disease Hannover (BREATH) im Deutschen Zentrum für Lungenforschung (DZL)
| | - Philipp Capetian
- Klinik für Neurologie, Neurologische Intensivstation, Universitätsklinikum Würzburg
| | - Uwe Hamsen
- Fachbereich für Unfallchirurgie und Orthopädie, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil, Bochum
| | - Uwe Janssens
- Innere Medizin und internistische Intensivmedizin, Sankt Antonius Hospital GmbH, Eschweiler
| | - Christian Karagiannidis
- Abteilung für Pneumologie und Beatmungsmedizin, ARDS/ECMO Zentrum, Lungenklinik Köln-Merheim
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Eppendorf, Hamburg
| | - Marco König
- Deutscher Berufsverband Rettungsdienst e. V., Lübeck
| | - Andreas Markewitz
- ehem. Klinik für Herz- und Gefäßchirurgie Bundeswehrzentralkrankenhaus Koblenz
| | - Monika Nothacker
- Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e. V., Marburg
| | | | | | - Wolfgang Veit
- Bundesverband der Organtransplantierten e. V., Marne
| | - Thomas Volk
- Klinik für Anästhesiologie, Intensivmedizin und Schmerztherapie, Universitätsklinikum des Saarlandes, Homburg/Saar
| | - Christian Witt
- Seniorprofessor Innere Medizin und Pneumologie, Charité Berlin
| | | | | | - Thomas Fühner
- Krankenhaus Siloah, Klinik für Pneumologie und Beatmungsmedizin, Klinikum Region Hannover.,Biomedical Research in End-stage and Obstructive Lung Disease Hannover (BREATH) im Deutschen Zentrum für Lungenforschung (DZL)
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Mokhlesi B, Won CH, Make BJ, Selim BJ, Sunwoo BY. Optimal Noninvasive Medicare Access Promotion: Patients with Hypoventilation Syndromes A Technical Expert Panel Report from the American College of Chest Physicians, the American Association for Respiratory Care, the American Academy of Sleep Medicine, and the American Thoracic Society. Chest 2021; 160:e377-e387. [PMID: 34339686 DOI: 10.1016/j.chest.2021.06.083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 05/27/2021] [Accepted: 06/17/2021] [Indexed: 10/20/2022] Open
Abstract
The existing coverage criteria for home noninvasive ventilation (NIV) do not recognize the diversity of hypoventilation syndromes and advances in technologies. This document summarizes the work of the Hypoventilation Syndromes Technical Expert Panel working group. The most pressing current coverage barriers identified were: 1) overreliance on arterial blood gases (particularly during sleep); 2) need to perform testing on prescribed oxygen; 3) requiring a sleep study to rule out obstructive sleep apnea as the cause of sustained hypoxemia; 4) need for spirometry; 5) need to demonstrate BPAP without a backup rate failure to qualify for BPAP S/T; and 6) qualifying hospitalized patients for home NIV therapy at the time of discharge. Critical evidence support for changes to current policies include randomized clinical trial evidence and clinical practice guidelines. In order to decrease morbidity-mortality by achieving timely access to NIV for patients with hypoventilation, particularly those with obesity hypoventilation syndrome, we make the following key suggestions: 1) Given the significant technological advances, we advise acceptance of surrogate noninvasive end tidal and transcutaneous PCO2 and venous blood gases in lieu of arterial blood gases,; 2) Not requiring PCO2 measures while on prescribed oxygen; 3) Not requiring a sleep study to avoid delays in care in patients being discharged from the hospital; 4) Remove spirometry as a requirement; 5) Not requiring BPAP without a backup rate failure to approve BPAP S/T. The overarching goal of the Technical Expert Panel is to establish pathways that improve clinicians' management capability to provide Medicare beneficiaries access to appropriate home NIV therapy. Adoption of these proposed suggestions would result in the right device, at the right time, for the right type of patients with hypoventilation syndromes.
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10
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Clinical considerations in providing intravenous sedation with midazolam for obese patients in dentistry. Br Dent J 2021; 230:587-593. [PMID: 33990742 DOI: 10.1038/s41415-021-2944-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 09/07/2020] [Indexed: 11/08/2022]
Abstract
The widespread prevalence of obesity continues to rise. Obesity and dental disease share common risk factors and so the demand for dental care for obese patients is escalating. For some of these patients, there is a corresponding need to be able to provide intravenous sedation safely when it is necessary and appropriate to do so. However, obesity often presents with multiple comorbidities and airway complexities, leading to more challenging management and potentially increased risk. The risk assessment process as well as patient monitoring and management strategies will be explored in this article. By reviewing the literature from dentistry and other medical specialties, we also aim to establish the potential benefit in administering supplemental oxygen and the use of capnography in monitoring this cohort of patients.
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Abstract
Obesity hypoventilation syndrome is the most frequent cause of chronic hypoventilation and is increasingly more common with rising obesity rates. It leads to considerable morbidity and mortality, particularly when not recognized and treated adequately. Long-term nocturnal noninvasive ventilation is the mainstay of treatment but evidence suggests that CPAP may be effective in stable patients. Specific perioperative management is required to reduce complications. Some unique syndromes associated with obesity and hypoventilation include rapid-onset obesity with hypoventilation, hypothalamic, autonomic dysregulation (ROHHAD), and Prader-Willi syndrome. Congenital central hypoventilation syndrome (early or late-onset) is a genetic disorder resulting in hypoventilation. Several acquired causes of chronic central hypoventilation also exist. A high level of clinical suspicion is required to appropriately diagnose and manage affected patients.
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12
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Ramírez Molina VR, Masa Jiménez JF, Gómez de Terreros Caro FJ, Corral Peñafiel J. Effectiveness of different treatments in obesity hypoventilation syndrome. Pulmonology 2020; 26:370-377. [PMID: 32553827 DOI: 10.1016/j.pulmoe.2020.05.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 05/15/2020] [Indexed: 12/23/2022] Open
Abstract
Obesity hypoventilation syndrome (OHS) is an undesirable consequence of obesity, defined as daytime hypoventilation, sleep disorder breathing and obesity; during the past few years the prevalence of extreme obesity has markedly increased worldwide consequently increasing the prevalence of OHS. Patients with OHS have a lower quality of life and a higher risk of unfavourable cardiometabolic consequences. Early diagnosis and effective treatment can lead to significant improvement in patient outcomes; therefore, such data has noticeably raised interest in the management and treatment of this sleep disorder. This paper will discuss the findings on the main current treatment modalities OHS will be discussed.
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Affiliation(s)
- V R Ramírez Molina
- Pulmonary and Sleep Medicine, Regional General Hospital N.2 of the Mexican Social Security Institute (IMSS), Querétaro, Mexico
| | - J F Masa Jiménez
- Division of Pulmonary Medicine, San Pedro de Alcántara Hospital, Cáceres, Spain; CIBER of Respiratory Diseases (CIBERES), Madrid, Spain.
| | | | - J Corral Peñafiel
- Division of Pulmonary Medicine, San Pedro de Alcántara Hospital, Cáceres, Spain
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Pilcher J, Thayabaran D, Ebmeier S, Williams M, Back G, Collie H, Richards M, Bibby S, Semprini R, Weatherall M, Beasley R. The effect of 50% oxygen on PtCO 2 in patients with stable COPD, bronchiectasis, and neuromuscular disease or kyphoscoliosis: randomised cross-over trials. BMC Pulm Med 2020; 20:125. [PMID: 32380988 PMCID: PMC7203892 DOI: 10.1186/s12890-020-1132-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Accepted: 04/03/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND High-concentration oxygen therapy causes increased arterial partial pressure of carbon dioxide (PaCO2) in patients with COPD, asthma, pneumonia, obesity and acute lung injury. The objective of these studies was to investigate whether this physiological response to oxygen therapy occurs in stable patients with neuromuscular disease or kyphoscoliosis, and bronchiectasis. METHODS Three randomised cross-over trials recruited stable patients with neuromuscular disease or kyphoscoliosis (n = 20), bronchiectasis (n = 24), and COPD (n = 24). Participants were randomised to receive 50% oxygen and 21% oxygen (air), each for 30 min, in randomly assigned order. The primary outcome was transcutaneous partial pressure of carbon dioxide (PtCO2) at 30 min. The primary analysis was a mixed linear model. RESULTS Sixty six of the 68 participants had baseline PtCO2 values < 45 mmHg. The intervention baseline adjusted PtCO2 difference (95% CI) between oxygen and room air after 30 min was 0.2 mmHg (- 0.4 to 0.9), P = 0.40; 0.5 mmHg (- 0.2 to 1.2), P = 0.18; and 1.3 mmHg (0.7 to 1.8), P < 0.001, in the neuromuscular/kyphoscoliosis, bronchiectasis and COPD participants respectively. CONCLUSIONS The small increase in PtCO2 in the stable COPD patients with high-concentration oxygen therapy contrasts with the marked increases in PaCO2 seen in the setting of acute exacerbations of COPD. This suggests that the model of studying the effects of high-concentration oxygen therapy in patients with stable respiratory disease is not generalisable to the use of oxygen therapy in the acute clinical setting. Appropriate studies of high-concentration compared to titrated oxygen in acute clinical settings are needed to determine if there is a risk of oxygen-induced hypercapnia in patients with neuromuscular disease, kyphoscoliosis or bronchiectasis. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry ACTRN12615000970549 Registered 16/9/15, ACTRN12615000971538 Registered 16/9/15 and ACTRN12615001056583 Registered 7/10/15.
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Affiliation(s)
- Janine Pilcher
- Medical Research Institute of New Zealand, Private Bag 7902, Wellington, 6242 New Zealand
- Capital & Coast District Health Board, Wellington, New Zealand
- Victoria University of Wellington, Wellington, New Zealand
| | - Darmiga Thayabaran
- Medical Research Institute of New Zealand, Private Bag 7902, Wellington, 6242 New Zealand
- Capital & Coast District Health Board, Wellington, New Zealand
| | - Stefan Ebmeier
- Medical Research Institute of New Zealand, Private Bag 7902, Wellington, 6242 New Zealand
- Capital & Coast District Health Board, Wellington, New Zealand
| | - Mathew Williams
- Medical Research Institute of New Zealand, Private Bag 7902, Wellington, 6242 New Zealand
| | - Geraldine Back
- Capital & Coast District Health Board, Wellington, New Zealand
| | - Hamish Collie
- Capital & Coast District Health Board, Wellington, New Zealand
| | - Michael Richards
- Medical Research Institute of New Zealand, Private Bag 7902, Wellington, 6242 New Zealand
- Capital & Coast District Health Board, Wellington, New Zealand
| | - Susan Bibby
- Medical Research Institute of New Zealand, Private Bag 7902, Wellington, 6242 New Zealand
- Capital & Coast District Health Board, Wellington, New Zealand
| | - Ruth Semprini
- Medical Research Institute of New Zealand, Private Bag 7902, Wellington, 6242 New Zealand
- Capital & Coast District Health Board, Wellington, New Zealand
| | | | - Richard Beasley
- Medical Research Institute of New Zealand, Private Bag 7902, Wellington, 6242 New Zealand
- Capital & Coast District Health Board, Wellington, New Zealand
- Victoria University of Wellington, Wellington, New Zealand
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Denault MH, Ruel C, Simon M, Bouchard PA, Simard S, Lellouche F. Evaluation of hyperoxia-induced hypercapnia in obese patients after cardiac surgery: a randomized crossover comparison of conservative and liberal oxygen administration. Can J Anaesth 2020; 67:194-202. [PMID: 31650500 DOI: 10.1007/s12630-019-01500-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 07/26/2019] [Accepted: 08/04/2019] [Indexed: 10/25/2022] Open
Abstract
PURPOSE Recent studies on patients with stable obesity-hypoventilation syndrome have raised concerns about hyperoxia-induced hypercapnia in this population. This study aimed to evaluate whether a higher oxygen saturation target would increase arterial partial pressure of carbon dioxide (PaCO2) in obese patients after coronary artery bypass grafting surgery (CABG). METHODS Obese patients having CABG were recruited. With a randomized crossover design, we compared two oxygenation strategies for 30 min each, immediately after extubation: a peripheral oxygen saturation (SpO2) target of ≥ 95% achieved with manual oxygen titration (liberal) and a SpO2 target of 90% achieved with FreeO2, an automated oxygen titration device (conservative). The main outcome was end-of-period arterial PaCO2. RESULTS Thirty patients were included. Mean (standard deviation [SD]) body mass index (BMI) was 34 (3) kg·m-2 and mean (SD) baseline partial pressure of carbon dioxide (PCO2) was 40.7 (3.1) mmHg. Mean (SD) end-of-period PaCO2 was 42.0 (5.4) mmHg in the conservative period, compared with 42.6 (4.6) mmHg in the liberal period [mean difference - 0.6 (95% confidence interval - 2.2 to 0.9) mmHg; P = 0.4]. Adjusted analysis for age, BMI, narcotics, and preoperative PaCO2 did not substantively change the results. Fourteen patients were retainers, showing an elevation in mean (SD) PaCO2 in the liberal period of 3.3 (4.1) mmHg. Eleven patients had the opposite response, with a mean (SD) end-of-period PaCO2 decrease of 1.8 (2.2) mmHg in the liberal period. Five patients had a neutral response. CONCLUSION This study did not show a clinically important increase in PaCO2 associated with higher SpO2 values in this specific population of obese patients after CABG. Partial pressure of carbon dioxide increased with liberal oxygen administration in almost half of the patients, but no predictive factor was identified. TRIAL REGISTRATION www.clinicaltrials.gov (NCT02917668); registered 25 September, 2016.
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Affiliation(s)
- Marie-Hélène Denault
- Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval Research Center, 2725 Chemin Ste-Foy, Quebec, QC, G1V 4G5, Canada.
| | - Carolanne Ruel
- Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval Research Center, 2725 Chemin Ste-Foy, Quebec, QC, G1V 4G5, Canada
| | - Mathieu Simon
- Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval Research Center, 2725 Chemin Ste-Foy, Quebec, QC, G1V 4G5, Canada
| | - Pierre-Alexandre Bouchard
- Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval Research Center, 2725 Chemin Ste-Foy, Quebec, QC, G1V 4G5, Canada
| | - Serge Simard
- Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval Research Center, 2725 Chemin Ste-Foy, Quebec, QC, G1V 4G5, Canada
| | - François Lellouche
- Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval Research Center, 2725 Chemin Ste-Foy, Quebec, QC, G1V 4G5, Canada
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Conway A, Collins P, Chang K, Mafeld S, Sutherland J, Fingleton J. Sequence analysis of capnography waveform abnormalities during nurse-administered procedural sedation and analgesia in the cardiac catheterization laboratory. Sci Rep 2019; 9:10214. [PMID: 31308455 PMCID: PMC6629622 DOI: 10.1038/s41598-019-46751-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Accepted: 07/04/2019] [Indexed: 11/17/2022] Open
Abstract
Identifying common patterns in capnography waveform abnormalities and the factors that influence these patterns could yield insights to optimize responses to sedation-induced respiratory depression. Respiratory state sequences for 102 patients who had a procedure in a cardiac catheterisation laboratory with procedural sedation and analgesia were developed by classifying each second of procedures into a state of normal breathing or other capnography waveform abnormalities based on pre-specified cut-offs for respiratory rate and end-tidal CO2 concentration. Hierarchical clustering identified four common patterns in respiratory state sequences, which were characterized by a predominance of the state assigned normal breathing (n = 42; 41%), hypopneic hypoventilation (n = 38; 38%), apnea (n = 15; 15%) and bradypneic hypoventilation (n = 7; 7%). A multivariable distance matrix regression model including demographic and clinical variables explained 28% of the variation in inter-individual differences in respiratory state sequences. Obstructive sleep apnea (R2 = 2.4%; p = 0.02), smoking status (R2 = 2.8%; p = 0.01), Charlson comorbidity index score (R2 = 2.5%; p = 0.021), peak transcutaneous carbon dioxide concentration (R2 = 4.1%; p = 0.002) and receiving an intervention to support respiration (R2 = 5.6%; p = 0.001) were significant covariates but each explained only small amounts of the variation in respiratory state sequences. Oxygen desaturation (SpO2 < 90%) was rare (n = 3; 3%) and not associated with respiratory state sequence trajectories.
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Affiliation(s)
- Aaron Conway
- Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Canada.
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Canada.
- Institute of Health and Biomedical Innovation, School of Nursing, Queensland University of Technology, Brisbane, Australia.
| | - Peter Collins
- Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Kristina Chang
- Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Sebastian Mafeld
- Interventional Radiology, Toronto General Hospital, University Health Network, Toronto, Canada
| | - Joanna Sutherland
- Department of Anaesthesia, Coffs Harbour Health Campus, Coffs Harbour, Australia
| | - James Fingleton
- Medical Research Institute of New Zealand, Wellington, New Zealand
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Patel B, Khine H, Shah A, Sung D, Medar S, Singer L. Randomized clinical trial of high concentration versus titrated oxygen use in pediatric asthma. Pediatr Pulmonol 2019; 54:970-976. [PMID: 30945478 DOI: 10.1002/ppul.24329] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 01/23/2019] [Accepted: 03/13/2019] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To compare the effects of high concentration to titrated oxygen therapy (HCOT) on transcutaneous carbon dioxide (PtCO2 ) level in pediatric asthma exacerbation. Titrated oxygen therapy (TOT) in acute asthma will avoid a rise in PtCO 2 in the pediatric population. METHOD The study design is a prospective, randomized, clinical trial comparing HCOT (maintain SpO2 92-95%) while being treated for asthma exacerbation in the emergency department (ED). INCLUSION CRITERIA 2 to 18 years, previously diagnosed asthma with acute exacerbation (asthma score >5). PtCO2 and asthma scores were measured at 0, 20, 40, 60 minutes and then every 30 minutes until disposition decision. The primary outcome was a change in PtCO 2 . Secondary outcomes were admission rate and change in asthma score. RESULTS A total of 96 patients were enrolled in the study with a mean age of 8.27 years; 49 in HCOT and 47 in the TOT group. The 0 minute PtCO2 was similar (35.33 + 3.88 HCOT vs 36.66 + 4.69 TOT, P = 0.13); whereas, the 60 minutes PtCO 2 was higher in the HCOT (38.08 + 5.11 HCOT vs 35.51 + 4.57 TOT, P = 0.01). The asthma score was similar at 0 minute (7.55 + 1.34 HCOT vs 7.30 + 1.18 TOT, P = 0.33); whereas, the 60 minutes asthma score was lower in the TOT (4.71 + 1.38 HCOT vs 3.57 + 1.25 TOT, P = 0.0001). The rate of admission to the hospital was 40.5% in HCOT vs 25.5% in the TOT (P = 0.088). CONCLUSIONS HCOT in pediatric asthma exacerbation leads to significantly higher carbon dioxide levels, which increases asthma scores and trends towards the increasing rate of admission. Larger studies are needed to explore this association.
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Affiliation(s)
- Bhavi Patel
- Department of Pediatric Critical Care, The Children's Hospital at Montefiore, Bronx, New York.,Department of Pediatric Cardiac Critical Care, Nicklaus Children's Hospital, Miami, Florida
| | - Hnin Khine
- Department of Pediatric Critical Care, The Children's Hospital at Montefiore, Bronx, New York
| | - Ami Shah
- Department of Pediatric Critical Care, The Children's Hospital at Montefiore, Bronx, New York
| | - Deborah Sung
- Department of Pediatric Critical Care, The Children's Hospital at Montefiore, Bronx, New York
| | - Shivanand Medar
- Department of Pediatric Critical Care, The Children's Hospital at Montefiore, Bronx, New York
| | - Lewis Singer
- Department of Pediatric Critical Care, The Children's Hospital at Montefiore, Bronx, New York
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Reply: Carbon Dioxide Narcosis or Sleep Deprivation? Ann Am Thorac Soc 2019; 16:778. [PMID: 30916987 PMCID: PMC6543469 DOI: 10.1513/annalsats.201903-204le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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McKinstry S, Singer J, Baarsma JP, Weatherall M, Beasley R, Fingleton J. Nasal high‐flow therapy compared with non‐invasive ventilation in COPD patients with chronic respiratory failure: A randomized controlled cross‐over trial. Respirology 2019; 24:1081-1087. [DOI: 10.1111/resp.13575] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 02/26/2019] [Accepted: 04/16/2019] [Indexed: 12/16/2022]
Affiliation(s)
- Steven McKinstry
- Medical Research Institute of New Zealand Wellington New Zealand
- Victoria University of Wellington Wellington New Zealand
- Capital and Coast District Health Board Wellington New Zealand
| | - Joseph Singer
- Medical Research Institute of New Zealand Wellington New Zealand
| | - Jan Pieter Baarsma
- Medical Research Institute of New Zealand Wellington New Zealand
- University of Groningen Groningen The Netherlands
| | - Mark Weatherall
- Capital and Coast District Health Board Wellington New Zealand
- University of Otago Wellington Wellington New Zealand
| | - Richard Beasley
- Medical Research Institute of New Zealand Wellington New Zealand
- Victoria University of Wellington Wellington New Zealand
- Capital and Coast District Health Board Wellington New Zealand
| | - James Fingleton
- Medical Research Institute of New Zealand Wellington New Zealand
- Victoria University of Wellington Wellington New Zealand
- Capital and Coast District Health Board Wellington New Zealand
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Benefits and risks of oxygen therapy during acute medical illness: Just a matter of dose! Rev Med Interne 2019; 40:670-676. [PMID: 31054779 DOI: 10.1016/j.revmed.2019.04.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 04/10/2019] [Indexed: 11/21/2022]
Abstract
Oxygen therapy is used to reverse hypoxemia since more than a century. Current usage is broader and includes routine oxygen administration despite normoxemia which may result in prolonged periods of hyperoxemia. While systematic oxygen therapy was expected to be of benefit in some ischemic diseases such as stroke or acute myocardial infarction, recent randomised controlled trials (RCTs) have challenged this hypothesis by showing the absence of clinical improvement. Although oxygen is known to be toxic at high inspired oxygen fractions, a recent meta-analysis of RCTs revealed the life-threatening effect of hyperoxemia, with a dose-dependent relationship. Several recommendations have therefore been updated: (i) to monitor peripheral oxygen saturation (SpO2) as a surrogate for arterial oxygen saturation (SaO2); (ii) to initiate oxygen only when the lower SpO2 threshold is crossed; (iii) to titrate the delivered oxygen fraction to maintain SpO2 within a target range; and (iv) to stop supplying oxygen when the upper limit of SpO2 is surpassed, in order to prevent hyperoxemia. The lower and upper limits of SpO2 depend on the presence of risk factors for oxygen-induced hypercapnia (Chronic obstructive pulmonary disease, asthma, and obesity-associated hypoventilation). For patients at risk, oxygen therapy should be started when SpO2 is≤88% and stopped when it is>92%. For patients without risk factors, oxygen therapy should be started when SpO2 is≤92% and stopped when it is >96%. High-flow oxygen should only be used in a few diseases such as carbon monoxide poisoning, cluster headaches, sickle cell crisis and pneumothorax.
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Sunwoo BY. Obesity Hypoventilation: Pathophysiology, Diagnosis, and Treatment. CURRENT PULMONOLOGY REPORTS 2019. [DOI: 10.1007/s13665-019-0223-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Affiliation(s)
- Richard Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Capital and Coast District Health Board, Wellington, New Zealand
- Victoria University of Wellington, Wellington, New Zealand
| | - Diane Mackle
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Capital and Coast District Health Board, Wellington, New Zealand
| | - Paul Young
- Medical Research Institute of New Zealand, Wellington, New Zealand
- Capital and Coast District Health Board, Wellington, New Zealand
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Bardsley G, Pilcher J, McKinstry S, Shirtcliffe P, Berry J, Fingleton J, Weatherall M, Beasley R. Oxygen versus air-driven nebulisers for exacerbations of chronic obstructive pulmonary disease: a randomised controlled trial. BMC Pulm Med 2018; 18:157. [PMID: 30285695 PMCID: PMC6171193 DOI: 10.1186/s12890-018-0720-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 09/10/2018] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND In exacerbations of chronic obstructive pulmonary disease, administration of high concentrations of oxygen may cause hypercapnia and increase mortality compared with oxygen titrated, if required, to achieve an oxygen saturation of 88-92%. Optimally titrated oxygen regimens require two components: titrated supplemental oxygen to achieve the target oxygen saturation and, if required, bronchodilators delivered by air-driven nebulisation. The effect of repeated air vs oxygen-driven bronchodilator nebulisation in acute exacerbations of chronic obstructive pulmonary disease is unknown. We aimed to compare the effects of air versus oxygen-driven bronchodilator nebulisation on arterial carbon dioxide tension in exacerbations of chronic obstructive pulmonary disease. METHODS A parallel group double-blind randomised controlled trial in 90 hospital in-patients with an acute exacerbation of COPD. Participants were randomised to receive two 2.5 mg salbutamol nebulisers, both driven by air or oxygen at 8 L/min, each delivered over 15 min with a 5 min interval in-between. The primary outcome measure was the transcutaneous partial pressure of carbon dioxide at the end of the second nebulisation (35 min). The primary analysis used a mixed linear model with fixed effects of the baseline PtCO2, time, the randomised intervention, and a time by intervention interaction term; to estimate the difference between randomised treatments at 35 min. Analysis was by intention-to-treat. RESULTS Oxygen-driven nebulisation was terminated in one participant after 27 min when the PtCO2 rose by > 10 mmHg, a predefined safety criterion. The mean (standard deviation) change in PtCO2 at 35 min was 3.4 (1.9) mmHg and 0.1 (1.4) mmHg in the oxygen and air groups respectively, difference (95% confidence interval) 3.3 mmHg (2.7 to 3.9), p < 0.001. The proportion of patients with a PtCO2 change ≥4 mmHg during the intervention was 18/45 (40%) and 0/44 (0%) for oxygen and air groups respectively. CONCLUSIONS Oxygen-driven nebulisation leads to an increase in PtCO2 in exacerbations of COPD. We propose that air-driven bronchodilator nebulisation is preferable to oxygen-driven nebulisation in exacerbations of COPD. TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry number ACTRN12615000389505 . Registration confirmed on 28/4/15.
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Affiliation(s)
- George Bardsley
- Capital and Coast District Health Board, Wellington, New Zealand
- Medical Research Institute of New Zealand, Box 7902, Wellington, PO 6242 New Zealand
| | - Janine Pilcher
- Capital and Coast District Health Board, Wellington, New Zealand
- Medical Research Institute of New Zealand, Box 7902, Wellington, PO 6242 New Zealand
- Victoria University Wellington, Wellington, New Zealand
| | - Steven McKinstry
- Capital and Coast District Health Board, Wellington, New Zealand
- Medical Research Institute of New Zealand, Box 7902, Wellington, PO 6242 New Zealand
- Victoria University Wellington, Wellington, New Zealand
| | - Philippa Shirtcliffe
- Capital and Coast District Health Board, Wellington, New Zealand
- Medical Research Institute of New Zealand, Box 7902, Wellington, PO 6242 New Zealand
| | - James Berry
- Medical Research Institute of New Zealand, Box 7902, Wellington, PO 6242 New Zealand
- Wellington School of Medicine & Health Sciences, University of Otago Wellington, Wellington, New Zealand
| | - James Fingleton
- Capital and Coast District Health Board, Wellington, New Zealand
- Medical Research Institute of New Zealand, Box 7902, Wellington, PO 6242 New Zealand
| | - Mark Weatherall
- Wellington School of Medicine & Health Sciences, University of Otago Wellington, Wellington, New Zealand
| | - Richard Beasley
- Capital and Coast District Health Board, Wellington, New Zealand
- Medical Research Institute of New Zealand, Box 7902, Wellington, PO 6242 New Zealand
- Victoria University Wellington, Wellington, New Zealand
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Kaw RK. Spectrum of postoperative complications in pulmonary hypertension and obesity hypoventilation syndrome. Curr Opin Anaesthesiol 2018; 30:140-145. [PMID: 27906717 DOI: 10.1097/aco.0000000000000420] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to identify chronic pulmonary conditions which may often not be recognized preoperatively especially before elective noncardiac surgery and which carry the highest risk of perioperative morbidity and mortality. RECENT FINDINGS This review discusses some of the most recent studies that highlight the perioperative complications, and their prevention and management strategies. SUMMARY Pulmonary hypertension is a well recognized risk factor for postoperative complications after cardiac surgery but the literature surrounding noncardiac surgery is sparse. Pulmonary hypertension was only recently classified as an independent risk factor for postoperative complications in the American Heart Association/American College of Cardiology Foundation Practice Guideline for noncardiac surgery. Spinal anesthesia should be avoided in most surgeries on patients with pulmonary hypertension because of it's rapid sympatholytic effects. The presence of significant right ventricle dysfunction and marked hypoxemia should prompt re-evaluation of the need for elective surgery. Obesity hypoventilation syndrome is even harder to recognize preoperatively as arterial blood gases are generally not obtained prior to elective noncardiac surgery. Amongst patients with obstructive sleep apnea this group of patients carries much higher risk of postoperative respiratory and congestive heart failure.
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Affiliation(s)
- Roop K Kaw
- Departments of Hospital Medicine and Anesthesiology Outcomes Research, Cleveland Clinic, Cleveland, Ohio, USA
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Pépin JL, Timsit JF, Tamisier R, Borel JC, Lévy P, Jaber S. Prevention and care of respiratory failure in obese patients. THE LANCET RESPIRATORY MEDICINE 2017; 4:407-18. [PMID: 27304558 DOI: 10.1016/s2213-2600(16)00054-0] [Citation(s) in RCA: 78] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Revised: 01/25/2016] [Accepted: 01/28/2016] [Indexed: 12/14/2022]
Abstract
With the increase in the global prevalence of obesity, there is a parallel rise in the proportion of obese patients admitted to intensive care units, referred for major surgery or requiring long-term non-invasive ventilation (NIV) at home for chronic respiratory failure. We describe the physiological effect of obesity on the respiratory system mainly in terms of respiratory mechanics, respiratory drive, and patency of the upper airways. Particular attention is given to the prevention and the clinical management of respiratory failure in obese patients with a main focus on invasive and NIV in intensive care during the perioperative period and long-term use of NIV on return home. We also address other aspects of care of obese patients, including antibiotic dosing and catheter-related infections.
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Affiliation(s)
- Jean Louis Pépin
- HP2 Laboratory, INSERM U1042, Grenoble Alpes University, Grenoble, France; EFCR Laboratory, Thorax and Vessels Division, Grenoble Alpes University Hospital, Grenoble, France.
| | - Jean François Timsit
- IAME, INSERM UMR 1137, Paris Diderot University, Paris, France; Medical and Infectious Diseases Intensive Care Unit, Paris Diderot University and Bichat Hospital, Paris, France
| | - Renaud Tamisier
- HP2 Laboratory, INSERM U1042, Grenoble Alpes University, Grenoble, France; EFCR Laboratory, Thorax and Vessels Division, Grenoble Alpes University Hospital, Grenoble, France
| | - Jean Christian Borel
- HP2 Laboratory, INSERM U1042, Grenoble Alpes University, Grenoble, France; EFCR Laboratory, Thorax and Vessels Division, Grenoble Alpes University Hospital, Grenoble, France
| | - Patrick Lévy
- HP2 Laboratory, INSERM U1042, Grenoble Alpes University, Grenoble, France; EFCR Laboratory, Thorax and Vessels Division, Grenoble Alpes University Hospital, Grenoble, France
| | - Samir Jaber
- Intensive Care Unit, Department of Anesthesia and Critical Care Medicine, University of Montpellier, Saint Eloi Teaching Hospital, Montpellier, France; Centre National de la Recherche Scientifique (CNRS 9214), Institut National de la Santé et de la Recherche Medicale (INSERM U-1046), Montpellier University, Montpellier, France
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Pilcher J, Richards M, Eastlake L, McKinstry SJ, Bardsley G, Jefferies S, Braithwaite I, Weatherall M, Beasley R. High flow or titrated oxygen for obese medical inpatients: a randomised crossover trial. Med J Aust 2017; 207:430-434. [PMID: 29129174 DOI: 10.5694/mja17.00270] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2017] [Accepted: 07/18/2017] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To compare the effects on transcutaneous carbon dioxide tension (Ptco2) of high concentration and titrated oxygen therapy in medical inpatients with morbid obesity who were not selected for a pre-existing diagnosis of obesity hypoventilation syndrome. DESIGN A randomised, crossover trial undertaken between February and September 2015. SETTING Internal medicine service, Wellington Regional Hospital, New Zealand. PARTICIPANTS 22 adult inpatients, aged 16 years or more, with a body mass index exceeding 40 kg/m<sup>2</sup>. INTERVENTIONS Participants received in random order two 60-minute interventions, with a minimum 30-minute washout period between treatments: titrated oxygen therapy (oxygen delivered, if required, via nasal prongs to achieve peripheral oxygen saturation [Spo2] of 88-92%), and high concentration oxygen therapy (delivered via Hudson mask at 8 L/min, without regard to Spo2). Ptco2 and Spo2 were recorded at 10-minute intervals. MAIN OUTCOME MEASURE Ptco2 at 60 minutes, adjusted for baseline. RESULTS Baseline Ptco2 was 45 mmHg or lower for 16 participants with full data (73%). The mean difference in Ptco2 between high concentration and titrated oxygen therapy at 60 minutes was 3.2 mmHg (95% CI, 1.3-5.2 mmHg; P = 0.002). CONCLUSION High concentration oxygen therapy increases Ptco2 in morbidly obese patients. Our findings support guidelines that advocate oxygen therapy, if required in patients with morbid obesity, be titrated to achieve a target Spo2 of 88-92%. CLINICAL TRIAL REGISTRATION Australian New Zealand Clinical Trials Registry, ACTRN12610000522011.
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Affiliation(s)
- Janine Pilcher
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Michael Richards
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Leonie Eastlake
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | | | - George Bardsley
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | - Sarah Jefferies
- Medical Research Institute of New Zealand, Wellington, New Zealand
| | | | - Mark Weatherall
- Wellington School of Medicine, University of Otago, Wellington, New Zealand
| | - Richard Beasley
- Medical Research Institute of New Zealand, Wellington, New Zealand
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O'Driscoll BR, Howard LS, Earis J, Mak V. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax 2017; 72:ii1-ii90. [DOI: 10.1136/thoraxjnl-2016-209729] [Citation(s) in RCA: 316] [Impact Index Per Article: 45.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 02/03/2017] [Accepted: 02/12/2017] [Indexed: 12/15/2022]
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Pilcher J, Eastlake L, Richards M, Power S, Cripps T, Bibby S, Braithwaite I, Weatherall M, Beasley R. Physiological effects of titrated oxygen via nasal high-flow cannulae in COPD exacerbations: A randomized controlled cross-over trial. Respirology 2017; 22:1149-1155. [DOI: 10.1111/resp.13050] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 02/23/2017] [Accepted: 02/26/2017] [Indexed: 12/17/2022]
Affiliation(s)
- Janine Pilcher
- Medical Research Institute of New Zealand; Wellington New Zealand
- Department of Clinical Research; Victoria University of Wellington School of Biological Science; Wellington New Zealand
- Department of Medicine; Capital and Coast District Health Board; Wellington New Zealand
| | - Leonie Eastlake
- Medical Research Institute of New Zealand; Wellington New Zealand
| | - Michael Richards
- Medical Research Institute of New Zealand; Wellington New Zealand
| | - Sharon Power
- Medical Research Institute of New Zealand; Wellington New Zealand
- Department of Medicine; Capital and Coast District Health Board; Wellington New Zealand
| | - Terrianne Cripps
- Medical Research Institute of New Zealand; Wellington New Zealand
- Department of Medicine; Capital and Coast District Health Board; Wellington New Zealand
| | - Susan Bibby
- Medical Research Institute of New Zealand; Wellington New Zealand
- Department of Medicine; Capital and Coast District Health Board; Wellington New Zealand
| | - Irene Braithwaite
- Medical Research Institute of New Zealand; Wellington New Zealand
- Department of Clinical Research; Victoria University of Wellington School of Biological Science; Wellington New Zealand
- Department of Medicine; Capital and Coast District Health Board; Wellington New Zealand
| | | | - Richard Beasley
- Medical Research Institute of New Zealand; Wellington New Zealand
- Department of Clinical Research; Victoria University of Wellington School of Biological Science; Wellington New Zealand
- Department of Medicine; Capital and Coast District Health Board; Wellington New Zealand
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Augelli DM, Krieger AC. Social and Economic Impacts of Managing Sleep Hypoventilation Syndromes. Sleep Med Clin 2017; 12:87-98. [DOI: 10.1016/j.jsmc.2016.10.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Liao P, Wong J, Singh M, Wong DT, Islam S, Andrawes M, Shapiro CM, White DP, Chung F. Postoperative Oxygen Therapy in Patients With OSA. Chest 2017; 151:597-611. [DOI: 10.1016/j.chest.2016.12.005] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 10/27/2016] [Accepted: 12/05/2016] [Indexed: 12/11/2022] Open
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Randerath W, Verbraecken J, Andreas S, Arzt M, Bloch KE, Brack T, Buyse B, De Backer W, Eckert DJ, Grote L, Hagmeyer L, Hedner J, Jennum P, La Rovere MT, Miltz C, McNicholas WT, Montserrat J, Naughton M, Pepin JL, Pevernagie D, Sanner B, Testelmans D, Tonia T, Vrijsen B, Wijkstra P, Levy P. Definition, discrimination, diagnosis and treatment of central breathing disturbances during sleep. Eur Respir J 2016; 49:13993003.00959-2016. [DOI: 10.1183/13993003.00959-2016] [Citation(s) in RCA: 169] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 08/25/2016] [Indexed: 02/07/2023]
Abstract
The complexity of central breathing disturbances during sleep has become increasingly obvious. They present as central sleep apnoeas (CSAs) and hypopnoeas, periodic breathing with apnoeas, or irregular breathing in patients with cardiovascular, other internal or neurological disorders, and can emerge under positive airway pressure treatment or opioid use, or at high altitude. As yet, there is insufficient knowledge on the clinical features, pathophysiological background and consecutive algorithms for stepped-care treatment. Most recently, it has been discussed intensively if CSA in heart failure is a “marker” of disease severity or a “mediator” of disease progression, and if and which type of positive airway pressure therapy is indicated. In addition, disturbances of respiratory drive or the translation of central impulses may result in hypoventilation, associated with cerebral or neuromuscular diseases, or severe diseases of lung or thorax. These statements report the results of an European Respiratory Society Task Force addressing actual diagnostic and therapeutic standards. The statements are based on a systematic review of the literature and a systematic two-step decision process. Although the Task Force does not make recommendations, it describes its current practice of treatment of CSA in heart failure and hypoventilation.
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Masa JF, Corral J, Romero A, Caballero C, Terán-Santos J, Alonso-Álvarez ML, Gomez-Garcia T, González M, López-Martínez S, De Lucas P, Marin JM, Marti S, Díaz-Cambriles T, Chiner E, Merchan M, Egea C, Obeso A, Mokhlesi B. The Effect of Supplemental Oxygen in Obesity Hypoventilation Syndrome. J Clin Sleep Med 2016; 12:1379-1388. [PMID: 27568890 DOI: 10.5664/jcsm.6194] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 06/27/2016] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Low flow supplemental oxygen is commonly prescribed to patients with obesity hypoventilation syndrome (OHS). However, there is a paucity of data regarding its efficacy and safety. The objective of this study was to assess the medium-term treatment efficacy of adding supplemental oxygen therapy to commonly prescribed treatment modalities in OHS. METHODS In this post hoc analysis of a previous randomized controlled trial, we studied 302 sequentially screened OHS patients who were randomly assigned to noninvasive ventilation, continuous positive airway pressure, or lifestyle modification. Outcomes at 2 mo included arterial blood gases, symptoms, quality of life, blood pressure, polysomnography, spirometry, 6-min walk distance, and hospital resource utilization. Statistical analysis comparing patients with and without oxygen therapy in the three treatment groups was performed using an intention-to-treat analysis. RESULTS In the noninvasive ventilation group, supplemental oxygen reduced systolic blood pressure although this could be also explained by a reduction in body weight experienced in this group. In the continuous positive airway pressure group, supplemental oxygen increased the frequency of morning confusion. In the lifestyle modification group, supplemental oxygen increased compensatory metabolic alkalosis and decreased the apnea-hypopnea index during sleep. Oxygen therapy was not associated with an increase in hospital resource utilization in any of the groups. CONCLUSIONS After 2 mo of follow-up, chronic oxygen therapy produced marginal changes that were insufficient to consider it, globally, as beneficial or deleterious. Because supplemental oxygen therapy did not increase hospital resource utilization, we recommend prescribing oxygen therapy to patients with OHS who meet criteria with close monitoring. Long-term studies examining outcomes such as incident cardiovascular morbidity and mortality are necessary. CLINICAL TRIALS REGISTRATION Clinicaltrial.gov, ID: NCT01405976.
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Affiliation(s)
- Juan F Masa
- San Pedro de Alcántara Hospital, Cáceres, Spain.,CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain
| | - Jaime Corral
- San Pedro de Alcántara Hospital, Cáceres, Spain.,CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain
| | | | | | - Joaquin Terán-Santos
- University Hospital, Burgos, Spain.,CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain
| | - Maria L Alonso-Álvarez
- University Hospital, Burgos, Spain.,CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain
| | | | | | | | | | - José M Marin
- Miguel Servet Hospital, Zaragoza, Spain.,CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain
| | - Sergi Marti
- Valld'Hebron Hospital, Barcelona, Spain.,CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain
| | - Trinidad Díaz-Cambriles
- Doce de Octubre Hospital, Madrid, Spain.,CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain
| | | | | | - Carlos Egea
- Sleep Unit, Respiratory Department, Alava University Hospital IRB, Vitoria, Spain.,CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain
| | - Ana Obeso
- Department of Physiology, University of Valladolid, Spain
| | - Babak Mokhlesi
- Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago, Chicago, IL
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Abstract
The prevalence of obesity hypoventilation syndrome and obstructive sleep apnea are increasing rapidly in the United States in parallel with the obesity epidemic. As the pathogenesis of this chronic illness is better understood, effective evidence-based therapies are being deployed to reduce morbidity and mortality. Nevertheless, patients with obesity hypoventilation still fall prey to at least four avoidable types of therapeutic errors, especially at the time of hospitalization for respiratory or cardiovascular decompensation: (1) patients with obesity hypoventilation syndrome may develop acute hypercapnia in response to administration of excessive supplemental oxygen; (2) excessive diuresis for peripheral edema using a loop diuretic such as furosemide exacerbates metabolic alkalosis, thereby worsening daytime hypoventilation and hypoxemia; (3) excessive or premature pharmacological treatment of psychiatric illnesses can exacerbate sleep-disordered breathing and worsen hypercapnia, thereby exacerbating psychiatric symptoms; and (4) clinicians often erroneously diagnose obstructive lung disease in patients with obesity hypoventilation, thereby exposing them to unnecessary and potentially harmful medications, including β-agonists and corticosteroids. Just as literary descriptions of pickwickian syndrome have given way to greater understanding of the pathophysiology of obesity hypoventilation, clinicians might exercise caution to consider these potential pitfalls and thus avoid inflicting unintended and avoidable complications.
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Marik PE, Chen C. The clinical characteristics and hospital and post-hospital survival of patients with the obesity hypoventilation syndrome: analysis of a large cohort. Obes Sci Pract 2016; 2:40-47. [PMID: 27812378 PMCID: PMC5067555 DOI: 10.1002/osp4.27] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 12/04/2015] [Accepted: 12/16/2015] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE The worldwide prevalence of obesity has reached epidemic proportions. Obesity hypoventilation syndrome (OHS) is a common yet largely undiagnosed and mistreated condition that likely carries a high mortality. The aim of this study was to determine the clinical characteristics, hospital outcome, outcome following hospital discharge and predictors of death in a large cohort of patients hospitalized with OHS. OHS is an important condition as many patients with this syndrome are misdiagnosed and receive inappropriate treatment. METHODS We reviewed the electronic medical records of patients with unequivocal OHS admitted to a 525-bed tertiary-care teaching hospital over a 5-year period. Demographic and clinical data as well as hospital disposition were recorded. In order to determine the patients' post-discharge status, we linked our database to the database of death certificates of the State Registrar of Vital Records. RESULTS We identified 600 patients who met the inclusion criteria for this study. The patients' mean age was 58 ± 15 years with a mean body mass index of 48.2 ± 8.3 kg m-2; 64% were women. Thirty-seven percent had a history of diabetes and 43% had been misdiagnosed as having chronic obstructive pulmonary disease, while none had been previously diagnosed with OHS. The most common admission diagnoses were respiratory failure, heart failure and sepsis. Ninety (15%) patients died during the index hospitalization. The patients' age, S-creatinine, respiratory failure, sepsis and admission to the ICU were independent predictors of hospital mortality. The hospital survivors were followed for a mean of 1,174 ± 501 d (3.2 ± 1.3 years) from the index hospitalization. On follow-up, 98 of the 510 (19%) hospital survivors died, with an overall cumulative mortality of 31.3%. The patients' age, S-creatinine and admission to the ICU were independent predictors of post-hospital mortality. CONCLUSION Obesity hypoventilation syndrome is a common disease that is frequently misdiagnosed and mistreated and carries a 3-year morality, which is significantly worse than that for most cancers combined. Considering the high mortality of this disease, all patients with a body mass index > 35 kg m-2 should be screened for OHS; those patients with both early and established OHS should be referred to a pulmonary and/or sleep specialist for evaluation for non-invasive positive pressure ventilation, to a dietician for dietary counseling and lifestyle modification and to a bariatric surgeon for evaluation for bariatric surgery.
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Affiliation(s)
- P E Marik
- Division of Pulmonary and Critical Care Medicine Eastern Virginia Medical School Norfolk VA USA
| | - C Chen
- Division of Pulmonary and Critical Care Medicine Eastern Virginia Medical School Norfolk VA USA
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Abstract
Obesity hypoventilation syndrome is becoming an increasingly encountered condition both in respiratory outpatient clinics and in hospitalized patients. The health consequences and social disadvantages of obesity hypoventilation syndrome are significant. Unfortunately, the diagnosis and institution of appropriate therapy is commonly delayed when the syndrome is not recognized or misdiagnosed. Positive airway pressure therapy remains the mainstay of treatment and is effective in controlling sleep-disordered breathing and improving awake blood gases in the majority of individuals. Evidence supporting one mode of therapy over another is limited. Both continuous and bilevel therapy modes can successfully improve daytime gas exchange, with adherence to therapy an important modifiable factor in the response to treatment. Despite adherence to therapy, these individuals continue to experience excess mortality primarily due to cardiovascular events compared with those with eucapnic sleep apnea using CPAP. This difference likely arises from ongoing systemic inflammation secondary to the morbidly obese state. The need for a comprehensive approach to managing nutrition, weight, and physical activity in addition to reversal of sleep-disordered breathing is now widely recognized. Future studies need to evaluate the impact of a more aggressive and comprehensive treatment plan beyond managing sleep-disordered breathing. The impact of early identification and treatment of sleep-disordered breathing on the development and reversal of cardiometabolic dysfunction also requires further attention.
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Affiliation(s)
- Amanda Piper
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, Camperdown, and Woolcock Institute of Medical Research, University of Sydney, Sydney, NSW, Australia.
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Beasley R, Chien J, Douglas J, Eastlake L, Farah C, King G, Moore R, Pilcher J, Richards M, Smith S, Walters H. Thoracic Society of Australia and New Zealand oxygen guidelines for acute oxygen use in adults: 'Swimming between the flags'. Respirology 2015; 20:1182-91. [PMID: 26486092 PMCID: PMC4654337 DOI: 10.1111/resp.12620] [Citation(s) in RCA: 122] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2015] [Accepted: 06/17/2015] [Indexed: 01/07/2023]
Abstract
The purpose of the Thoracic Society of Australia and New Zealand guidelines is to provide simple, practical evidence-based recommendations for the acute use of oxygen in adults in clinical practice. The intended users are all health professionals responsible for the administration and/or monitoring of oxygen therapy in the management of acute medical patients in the community and hospital settings (excluding perioperative and intensive care patients), those responsible for the training of such health professionals, and both public and private health care organizations that deliver oxygen therapy.
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Affiliation(s)
- Richard Beasley
- Medical Research Institute of New ZealandWellington, New Zealand
- Wellington Regional Hospital, Capital and Coast District Health BoardWellington, New Zealand
| | - Jimmy Chien
- Department of Respiratory and Sleep Medicine, Ludwig Engel Centre for Respiratory Research, Westmead Millennium Institute, University of Sydney at Westmead HospitalSydney, New South Wales, Australia
| | - James Douglas
- Thoracic Program, The Prince Charles HospitalBrisbane, Queensland, Australia
| | - Leonie Eastlake
- Medical Research Institute of New ZealandWellington, New Zealand
| | - Claude Farah
- Department of Respiratory Medicine, Concord HospitalSydney, New South Wales, Australia
- Physiology and Imaging Group, Woolcock Institute of Medical ResearchSydney, New South Wales, Australia
- Sydney Medical School, University of SydneySydney, New South Wales, Australia
- Australian School of Advanced Medicine, Macquarie UniversitySydney, New South Wales, Australia
| | - Gregory King
- Physiology and Imaging Group, Woolcock Institute of Medical ResearchSydney, New South Wales, Australia
- Sydney Medical School, University of SydneySydney, New South Wales, Australia
- Department of Respiratory Medicine, Royal North Shore HospitalSydney, New South Wales, Australia
| | - Rosemary Moore
- Institute for Breathing and Sleep, Austin HealthMelbourne, Victoria, Australia
| | - Janine Pilcher
- Medical Research Institute of New ZealandWellington, New Zealand
- Wellington Regional Hospital, Capital and Coast District Health BoardWellington, New Zealand
- School of Biological Sciences, Victoria University of WellingtonWellington, New Zealand
| | - Michael Richards
- Medical Research Institute of New ZealandWellington, New Zealand
| | - Sheree Smith
- School of Nursing and Midwifery, University of Western SydneySydney, New South Wales, Australia
| | - Haydn Walters
- CRE for Chronic Respiratory Disease, University of TasmaniaHobart, Tasmania, Australia
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Povitz M, Hanly PJ, Pendharkar SR, James MT, Tsai WH. Treatment of Sleep Disordered Breathing Liberates Obese Hypoxemic Patients from Oxygen. PLoS One 2015; 10:e0140135. [PMID: 26451835 PMCID: PMC4599852 DOI: 10.1371/journal.pone.0140135] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Accepted: 09/22/2015] [Indexed: 11/18/2022] Open
Abstract
Background Obese hypoxemic patients have a high prevalence of sleep disordered breathing (SDB). It is unclear to what extent treatment of SDB can improve daytime hypoxemia. Methods We performed a retrospective cohort study of obese hypoxemic individuals, all of whom underwent polysomnography, arterial blood gas analysis, and subsequent initiation of positive airway pressure (PAP) therapy for SDB. Patients were followed for one year for change in partial pressure of arterial oxygen and the need for supplemental oxygen. Results One hundred and seventeen patients were treated with nocturnal PAP and had follow-up available. Adherence to PAP was satisfactory in 60%, and was associated with a significant improvement in daytime hypoxemia and hypercapnea; 56% of these patients were able to discontinue supplemental oxygen. Adherence to PAP therapy and the baseline severity of OSA predicted improvement in hypoxemia, but only adherence to PAP therapy predicted liberation from supplemental oxygen. Conclusions The identification and treatment of SDB in obese hypoxemic patients improves daytime hypoxemia. It is important to identify SDB in these patients, since supplemental oxygen can frequently be discontinued following treatment with PAP therapy.
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Affiliation(s)
- Marcus Povitz
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, Western University, London, Ontario, Canada
| | - Patrick J. Hanly
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Sleep Centre, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Sachin R. Pendharkar
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Sleep Centre, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Matthew T. James
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Willis H. Tsai
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
- Department of Medicine, University of Calgary, Calgary, Alberta, Canada
- Sleep Centre, Foothills Medical Centre, Calgary, Alberta, Canada
- * E-mail:
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Prevalence of Sleep-disordered Breathing in Obese Patients with Chronic Hypoxemia. A Cross-Sectional Study. Ann Am Thorac Soc 2015; 12:921-7. [DOI: 10.1513/annalsats.201412-551oc] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Pilcher J, Weatherall M, Perrin K, Beasley R. Oxygen therapy in acute exacerbations of chronic obstructive pulmonary disease. Expert Rev Respir Med 2015; 9:287-93. [DOI: 10.1586/17476348.2015.1016503] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Abstract
This article summarizes available data on the obesity hypoventilation syndrome and its pertinence to intensivists, outlines clinical and pathophysiologic aspects of the disease, discusses multidisciplinary treatments, and reviews the available literature on outcomes specific to the critically ill patient.
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Affiliation(s)
- Shirley F Jones
- Division of Pulmonary Critical Care and Sleep Medicine, Department of Medicine, Baylor Scott &White Health, Texas A&M Health Science Center, 2401 South 31st Street, Temple, TX 76508, USA.
| | - Veronica Brito
- Division of Pulmonary Critical Care and Sleep Medicine, Department of Medicine, Baylor Scott &White Health, Texas A&M Health Science Center, 2401 South 31st Street, Temple, TX 76508, USA
| | - Shekhar Ghamande
- Division of Pulmonary Critical Care and Sleep Medicine, Department of Medicine, Baylor Scott &White Health, Texas A&M Health Science Center, 2401 South 31st Street, Temple, TX 76508, USA
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Love L, Cline MG. Perioperative physiology and pharmacology in the obese small animal patient. Vet Anaesth Analg 2015; 42:119-32. [DOI: 10.1111/vaa.12219] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2014] [Accepted: 07/02/2014] [Indexed: 01/08/2023]
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Abstract
Obesity hypoventilation syndrome is a respiratory consequence of morbid obesity that is characterized by alveolar hypoventilation during sleep and wakefulness. The disorder involves a complex interaction between impaired respiratory mechanics, ventilatory drive and sleep-disordered breathing. Early diagnosis and treatment is important, because delay in treatment is associated with significant mortality and morbidity. Available treatment options include non-invasive positive airway pressure (PAP) therapies and weight loss. There is limited long-term data regarding the effectiveness of such therapies. This review outlines the current concepts of clinical presentation, diagnostic and management strategies to help identify and treat patients with obesity-hypoventilation syndromes.
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Kaw R, Argalious M, Aboussouan LS, Chung F. Obesity Hypoventilation Syndrome and Anesthesia Considerations. Sleep Med Clin 2014. [DOI: 10.1016/j.jsmc.2014.05.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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L’oxygénothérapie dans tous ces états ou comment administrer l’oxygène en 2014 ? MEDECINE INTENSIVE REANIMATION 2014. [DOI: 10.1007/s13546-014-0839-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Hollier CA, Harmer AR, Maxwell LJ, Menadue C, Willson GN, Unger G, Flunt D, Black DA, Piper AJ. Moderate concentrations of supplemental oxygen worsen hypercapnia in obesity hypoventilation syndrome: a randomised crossover study. Thorax 2013; 69:346-53. [DOI: 10.1136/thoraxjnl-2013-204389] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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