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Chang M, Moore V, Eng K, Ryden A, Zeidler M. Hypoglossal nerve stimulation over-titration. J Clin Sleep Med 2024. [PMID: 38415706 DOI: 10.5664/jcsm.11066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Abstract
This case report reviews worsening obstructive sleep apnea (OSA) events in a patient over-titrated with a hypoglossal nerve stimulator (HNS). A healthy 57-year-old man underwent HNS implantation for moderate OSA. During an in- laboratory HNS titration the patient had improvement of his OSA at 2.1V. However further increase of voltage resulted in worsening of obstructive events. The pathophysiology behind this finding is unknown but may result from unfavorable changes in the upper anatomy due to higher energy delivered to the hypoglossal nerve and surrounding structures. This high energy may also lead to genioglossus muscle fatigue. This finding highlights the importance of hypoglossal nerve stimulation titration with a dedicated sleep study.
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Affiliation(s)
- Melisa Chang
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Veterans Affairs Greater Los Angeles Healthcare System
- David Geffen School of Medicine at UCLA, Division of Pulmonary, Critical Care & Sleep Medicine
| | - Virginia Moore
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Veterans Affairs Greater Los Angeles Healthcare System
| | - Kevin Eng
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Veterans Affairs Greater Los Angeles Healthcare System
- David Geffen School of Medicine at UCLA, Division of Pulmonary, Critical Care & Sleep Medicine
| | - Armand Ryden
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Veterans Affairs Greater Los Angeles Healthcare System
- David Geffen School of Medicine at UCLA, Division of Pulmonary, Critical Care & Sleep Medicine
| | - Michelle Zeidler
- Department of Medicine, Division of Pulmonary, Critical Care, and Sleep Medicine, Veterans Affairs Greater Los Angeles Healthcare System
- David Geffen School of Medicine at UCLA, Division of Pulmonary, Critical Care & Sleep Medicine
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Ferraro VA, Baraldi E, Stabinger D, Zamunaro A, Zanconato S, Carraro S. Pediatric flexible bronchoscopy: A single-center report. Pediatr Pulmonol 2021; 56:2634-2641. [PMID: 33969642 PMCID: PMC8360175 DOI: 10.1002/ppul.25458] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 04/16/2021] [Accepted: 05/02/2021] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Pediatric flexible laryngotracheal bronchoscopy (FB) is an integral part of diagnostics and treatment at tertiary pediatric respiratory centers. AIM FBs performed between 2013 and 2018 at our Pediatric Allergy and Respiratory Medicine Unit of the Department of Women's and Children's Health at Padua University were examined in terms of the indications, findings, and adverse events. MATERIALS AND METHODS The electronic medical records of pediatric patients who underwent FB at least once between 1 January 2013 and 31 December 2018 were considered. Patients' clinical data, indications for FB, anatomical findings, information derived from bronchoalveolar lavage (BAL) and bronchial brushing, and possible adverse events were analyzed. RESULTS There were 447 pediatric FBs performed in 428 patients (aged from 1 month to 18 years) for diagnostic purposes (92.4%), to clear secretions (3.6%), or to monitor a known condition (4.0%). The main indications were recurrent lower respiratory tract infections (LRTI, 32.2%) and chronic wet cough (9.4%). Lower airway malacia was the most common abnormal finding in these two groups (36.1% and 28.6%, respectively). BAL bacterial culture was positive in 55 children (39.6%) with recurrent LRTI and in 25 (59.5%) with chronic wet cough, being Haemophilus influenzae, Streptococcus pneumoniae, and Moraxella catarrhalis the microorganisms most commonly isolated. FB proved a safe procedure and was well tolerated. CONCLUSIONS Pediatric FB is an essential tool at our tertiary pediatric respiratory center. It helps establish the anatomical conditions underlying several chronic respiratory conditions and any correlated microbiological findings, with a significant impact on further patient management.
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Affiliation(s)
| | - Eugenio Baraldi
- Department of Women's and Children's Health, University of Padova, Padua, Italy
| | - Diana Stabinger
- Department of Women's and Children's Health, University of Padova, Padua, Italy
| | - Andrea Zamunaro
- Department of Women's and Children's Health, University of Padova, Padua, Italy
| | - Stefania Zanconato
- Department of Women's and Children's Health, University of Padova, Padua, Italy
| | - Silvia Carraro
- Department of Women's and Children's Health, University of Padova, Padua, Italy
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Abstract
Infants and children undergoing craniofacial surgery may present with a wide range of diseases and conditions posing an array of challenges to the anesthesiologist. Optimal perioperative care requires an understanding of these diseases and their impact on airway and anesthetic management. For those children with anomalies affecting airway anatomy, soft tissues of the head and neck, or skeletal mobility, advanced airway management techniques (ie, modalities other than direct laryngoscopy) may be required to secure the airway. Additionally, some craniofacial surgical procedures have direct implications on airway management, such as with Le Fort III midface advancement involving halo distractor application, where the distractor device precludes facemask ventilation. For all of these patients, the anesthetic and airway management plans must be tailored to the surgery being performed, the patient's specific conditions, and take into consideration all phases of perioperative care. In this review, we present some of the more commonly encountered craniofacial abnormalities affecting airway management.
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Affiliation(s)
- Annery G Garcia-Marcinkiewicz
- The Children's Hospital of Philadelphia, Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Paul A Stricker
- The Children's Hospital of Philadelphia, Department of Anesthesiology and Critical Care, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
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Lee SM, Wojtczak JA, Cattano D. Ultrasound comparison of external and internal neck anatomy with the LMA Unique. J Ultrason 2017; 17:229-234. [PMID: 29375896 PMCID: PMC5769661 DOI: 10.15557/jou.2017.0033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 11/13/2017] [Accepted: 11/17/2017] [Indexed: 11/22/2022] Open
Abstract
Introduction Internal neck anatomy landmarks and their relation after placement of an extraglottic airway devices have not been studied extensively by the use of ultrasound. Based on our group experience with external landmarks as well as internal landmarks evaluation with other techniques, we aimed use ultrasound to analyze the internal neck anatomy landmarks and the related changes due to the placement of the Laryngeal Mask Airway Unique. Methods Observational pilot investigation. Non-obese adult patients with no evidence of airway anomalies, were recruited. External neck landmarks were measured based on a validated and standardized method by tape. Eight internal anatomical landmarks, reciprocal by the investigational hypothesis to the external landmarks, were also measured by ultrasound guidance. The internal landmarks were re-measured after optimal placement and inflation of the extraglottic airway devices cuff Laryngeal Mask Airway Unique. Results Six subjects were recruited. Ultrasound measurements of hyoid-mental distance, thyroid-cricoid distance, thyroid height, and thyroid width were found to be significantly (p < 0.05) overestimated using a tape measure. Sagittal neck landmark distances such as thyroid height, sternal-mental distance, and thyroid-cricoid distance significantly decreased after placement of the Laryngeal Mask Airway Unique. Conclusion The laryngeal mask airway Unique resulted in significant changes in internal neck anatomy. The induced changes and respective specific internal neck anatomy landmarks could help to design devices that would modify their shape accordingly to areas of greatest displacement. Also, while external neck landmark measurements overestimate their respective internal neck landmarks, as we previously reported, the concordance of each measurement and their respective conversion factor could continue to be of help in sizing extraglottic airway devices. Due to the pilot nature of the study, more investigations are warranted.
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Affiliation(s)
- Steven M Lee
- McGovern Medical School, Department of Anesthesiology, UTHealth at Houston, Houston, TX, USA
| | - Jacek A Wojtczak
- University of Rochester, Department of Anesthesiology, Rochester, New York, USA
| | - Davide Cattano
- McGovern Medical School, Department of Anesthesiology, UTHealth at Houston, Houston, TX, USA
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O'donoghue FJ, Meaklim H, Bilston L, Hatt A, Connelly A, Jackson G, Farquharson S, Sutherland K, Cistulli PA, Brown DJ, Berlowitz DJ. Magnetic resonance imaging of the upper airway in patients with quadriplegia and obstructive sleep apnea. J Sleep Res 2017; 27:e12616. [PMID: 29082563 DOI: 10.1111/jsr.12616] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Accepted: 08/24/2017] [Indexed: 11/29/2022]
Abstract
The aim of this study was to investigate upper airway anatomy in quadriplegics with obstructive sleep apnea. Fifty subjects were recruited from three hospitals in Australia: people with quadriplegia due to spinal cord injury and obstructive sleep apnea (n = 11), able-bodied people with obstructive sleep apnea (n = 18), and healthy, able-bodied controls (n = 19). All underwent 3-Tesla magnetic resonance imaging of their upper airway. A subgroup (n = 34) received a topical vasoconstrictor, phenylephrine and post-phenylephrine magnetic resonance imaging. Mixed-model analysis indicated no significant differences in total airway lumen volume between the three groups (P = 0.086). Spinal cord injury-obstructive sleep apnea subjects had a significantly larger volume of soft palate (P = 0.020) and retroglossal lateral pharyngeal walls (P = 0.043) than able-bodied controls. Able-bodied-obstructive sleep apnea subjects had a smaller mandible volume than spinal cord injury-obstructive sleep apnea subjects and able-bodied control subjects (P = 0.036). No differences were seen in airway length between groups when controlling for height (P = 0.055). There was a marginal increase in velopharyngeal volume across groups post-phenylephrine (P = 0.050), and post hoc testing indicated the difference was confined to the able-bodied-obstructive sleep apnea group (P < 0.001). No other upper airway structures showed significant changes with phenylephrine administration. In conclusion, people with obstructive sleep apnea and quadriplegia do not have a structurally smaller airway than able-bodied subjects. They did, however, have greater volumes of soft palate and lateral pharyngeal walls, possibly due to greater neck fat deposition. The acute response to upper airway topical vasoconstriction was not enhanced in those with obstructive sleep apnea and quadriplegia. Changes in upper airway anatomy likely contribute to the high incidence in obstructive sleep apnea in quadriplegic subjects.
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Affiliation(s)
- Fergal J O'donoghue
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Vic, Australia.,Melbourne Brain Centre, The Florey Institute of Neuroscience and Mental Health, Heidelberg, Vic, Australia.,Faculty of Medicine Dentistry and Health Sciences, University of Melbourne, Parkville, Vic, Australia
| | - Hailey Meaklim
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Vic, Australia.,Melbourne Brain Centre, The Florey Institute of Neuroscience and Mental Health, Heidelberg, Vic, Australia
| | - Lynne Bilston
- Neuroscience Research Australia, Randwick, NSW, Australia.,University of New South Wales, Randwick, NSW, Australia
| | - Alice Hatt
- Neuroscience Research Australia, Randwick, NSW, Australia
| | - Alan Connelly
- Melbourne Brain Centre, The Florey Institute of Neuroscience and Mental Health, Heidelberg, Vic, Australia
| | - Graeme Jackson
- Melbourne Brain Centre, The Florey Institute of Neuroscience and Mental Health, Heidelberg, Vic, Australia.,Faculty of Medicine Dentistry and Health Sciences, University of Melbourne, Parkville, Vic, Australia
| | - Shawna Farquharson
- Melbourne Brain Centre, The Florey Institute of Neuroscience and Mental Health, Heidelberg, Vic, Australia
| | - Kate Sutherland
- Department of Respiratory and Sleep Medicine, Royal North Shore Hospital and Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Peter A Cistulli
- Department of Respiratory and Sleep Medicine, Royal North Shore Hospital and Sydney Medical School, University of Sydney, Sydney, NSW, Australia
| | - Douglas J Brown
- Spinal Research Institute, Austin Health, Heidelberg, Vic, Australia
| | - David J Berlowitz
- Institute for Breathing and Sleep, Austin Health, Heidelberg, Vic, Australia.,Faculty of Medicine Dentistry and Health Sciences, University of Melbourne, Parkville, Vic, Australia.,Spinal Research Institute, Austin Health, Heidelberg, Vic, Australia
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Carberry JC, Jordan AS, White DP, Wellman A, Eckert DJ. Upper Airway Collapsibility (Pcrit) and Pharyngeal Dilator Muscle Activity are Sleep Stage Dependent. Sleep 2016; 39:511-21. [PMID: 26612386 DOI: 10.5665/sleep.5516] [Citation(s) in RCA: 109] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2015] [Accepted: 10/15/2015] [Indexed: 11/03/2022] Open
Abstract
STUDY OBJECTIVES An anatomically narrow/highly collapsible upper airway is the main cause of obstructive sleep apnea (OSA). Upper airway muscle activity contributes to airway patency and, like apnea severity, can be sleep stage dependent. Conversely, existing data derived from a small number of participants suggest that upper airway collapsibility, measured by the passive pharyngeal critical closing pressure (Pcrit) technique, is not sleep stage dependent. This study aimed to determine the effect of sleep stage on Pcrit and upper airway muscle activity in a larger cohort than previously tested. METHODS Pcrit and/or muscle data were obtained from 72 adults aged 20-64 y with and without OSA.Pcrit was determined via transient reductions in continuous positive airway pressure (CPAP) during N2, slow wave sleep (SWS) and rapid eye movement (REM) sleep. Genioglossus and tensor palatini muscle activities were measured: (1) awake with and without CPAP, (2) during stable sleep on CPAP, and (3) in response to the CPAP reductions used to quantify Pcrit. RESULTS Pcrit was 4.9 ± 1.4 cmH2O higher (more collapsible) during REM versus SWS (P = 0.012), 2.3 ± 0.6 cmH2O higher during REM versus N2 (P < 0.001), and 1.6 ± 0.7 cmH2O higher in N2 versus SWS (P = 0.048). Muscle activity decreased from wakefulness to sleep and from SWS to N2 to REM sleep for genioglossus but not for tensor palatini. Pharyngeal muscle activity increased by ∼50% by breath 5 following CPAP reductions. CONCLUSIONS Upper airway collapsibility measured via the Pcrit technique and genioglossus muscle activity vary with sleep stage. These findings should be taken into account when performing and interpreting "passive" Pcrit measurements.
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Affiliation(s)
- Jayne C Carberry
- Neuroscience Research Australia (NeuRA) and the School of Medical Sciences, University of New South Wales, Sydney, New South Wales, Australia
| | - Amy S Jordan
- Melbourne School of Psychological Sciences, University of Melbourne, Parkville and Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia
| | - David P White
- Division of Sleep Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Andrew Wellman
- Division of Sleep Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - Danny J Eckert
- Neuroscience Research Australia (NeuRA) and the School of Medical Sciences, University of New South Wales, Sydney, New South Wales, Australia
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Bacharier LB. Early-life weight gain, prematurity, and asthma development. J Allergy Clin Immunol 2014; 133:1330-1. [PMID: 24766877 DOI: 10.1016/j.jaci.2014.03.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Accepted: 03/18/2014] [Indexed: 12/01/2022]
Affiliation(s)
- Leonard B Bacharier
- Department of Pediatrics, Washington University and St Louis Children's Hospital, St Louis, Mo.
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