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Pappu A, Ramachandran SK, Auckley D, Won C, Gali B, Hargett M, Nafiu O, Dominguez J, Singh M. Meeting Report: 11th and 12th Annual Meetings of the Society of Anesthesia and Sleep Medicine: Taking Sleep Health Into the Next Decade. Anesth Analg 2023; 137:e45-e48. [PMID: 37733625 DOI: 10.1213/ane.0000000000006632] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Affiliation(s)
- Ameya Pappu
- From the Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Satya Krishna Ramachandran
- Department of Anesthesia, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts
| | - Dennis Auckley
- Division of Pulmonary, Critical Care and Sleep Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Christine Won
- Section of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Yale University, New Haven, Connecticut
| | - Bhargavi Gali
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mary Hargett
- Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, New York
| | - Olubukola Nafiu
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Ohio, Columbus, Ohio
| | - Jennifer Dominguez
- Department of Anesthesiology, Duke University School of Medicine, Durham, North Carolina
| | - Mandeep Singh
- From the Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
- Department of Anesthesiology, Women's College Hospital, Toronto, Ontario, Canada
- Toronto Sleep and Pulmonary Center, Toronto, Ontario, Canada
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Kumar G, Auckley D, Merrick T, Breckenridge M, Carter JC, Ali M. False positive urine amphetamine immunoassay due to solriamfetol. Sleep Med 2023; 110:297-299. [PMID: 37708619 DOI: 10.1016/j.sleep.2023.08.031] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 08/29/2023] [Indexed: 09/16/2023]
Abstract
Solriamfetol is a schedule IV-controlled substance used to treat excessive daytime sleepiness resulting from narcolepsy or obstructive sleep apnea. We present a patient prescribed solriamfetol who tested positive for amphetamines on a routine urinary toxicology screen despite patient denial of illicit drug use, raising the possibility of a false positive amphetamine screen. Spiking studies were performed on negative urine, and different concentrations of solriamfetol drug on 2 different amphetamine assays: the commonly used Beckman Emit® II Plus Amphetamines Assay, and the Citrine™ Triple Quad™ MS/MS Systems. The Beckman yielded positive results for amphetamines at solriamfetol concentrations of 200 μg/mL and 2000 μg/mL and negative results at 0.2 μg/mL and 2 μg/mL. However, the Citrine™ Triple Quad™ MS/MS Systems was negative at all concentrations. The Beckman Emit® II Plus Amphetamine Assay gave false positive results for amphetamines due to solriamfetol drug usage, a finding of relevance to prescribers of solriamfetol.
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Affiliation(s)
- Gopal Kumar
- Department of Pathology, MetroHealth System, Cleveland, OH, USA; Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Dennis Auckley
- Case Western Reserve University School of Medicine, Cleveland, OH, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, MetroHealth System Cleveland, OH, USA.
| | - Troy Merrick
- Department of Pathology, MetroHealth System, Cleveland, OH, USA
| | | | - John C Carter
- Case Western Reserve University School of Medicine, Cleveland, OH, USA; Division of Pulmonary, Critical Care, and Sleep Medicine, MetroHealth System Cleveland, OH, USA
| | - Mahesheema Ali
- Department of Pathology, MetroHealth System, Cleveland, OH, USA; Case Western Reserve University School of Medicine, Cleveland, OH, USA
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Lukachan GA, Yadollahi A, Auckley D, Gavrilovic B, Matelski J, Chung F, Singh M. The impact of semi-upright position on severity of sleep disordered breathing in patients with obstructive sleep apnea: a two-arm, prospective, randomized controlled trial. BMC Anesthesiol 2023; 23:236. [PMID: 37443016 PMCID: PMC10339502 DOI: 10.1186/s12871-023-02193-y] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Accepted: 06/30/2023] [Indexed: 07/15/2023] Open
Abstract
BACKGROUND The severity of sleep-disordered breathing is known to worsen postoperatively and is associated with increased cardio-pulmonary complications and increased resource implications. In the general population, the semi-upright position has been used in the management of OSA. We hypothesized that the use of a semi-upright position versus a non-elevated position will reduce postoperative worsening of OSA in patients undergoing non-cardiac surgeries. METHODS This study was conducted as a prospective randomized controlled trial of perioperative patients, undergoing elective non-cardiac inpatient surgeries. Patients underwent a preoperative sleep study using a portable polysomnography device. Patients with OSA (apnea hypopnea index (AHI) > 5 events/hr), underwent a sleep study on postoperative night 2 (N2) after being randomized into an intervention group (Group I): semi-upright position (30 to 45 degrees incline), or a control group (Group C) (zero degrees from horizontal). The primary outcome was postoperative AHI on N2. The secondary outcomes were obstructive apnea index (OAI), central apnea index (CAI), hypopnea index (HI), obstructive apnea hypopnea index (OAHI) and oxygenation parameters. RESULTS Thirty-five patients were included. Twenty-one patients were assigned to the Group 1 (females-14 (67%); mean age 65 ± 12) while there were fourteen patients in the Group C (females-5 (36%); mean age 63 ± 10). The semi-upright position resulted in a significant reduction in OAI in the intervention arm (Group C vs Group I postop AHI: 16.6 ± 19.0 vs 8.6 ± 11.2 events/hr; overall p = 0.01), but there were no significant differences in the overall AHI or other parameters between the two groups. Subgroup analysis of patients with "supine related OSA" revealed a decreasing trend in postoperative AHI with semi-upright position, but the sample size was too small to evaluate statistical significance. CONCLUSION In patients with newly diagnosed OSA, the semi-upright position resulted in improvement in obstructive apneas, but not the overall AHI. TRIAL REGISTRATION This trial was retrospectively registered in clinicaltrials.gov NCT02152202 on 02/06/2014.
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Affiliation(s)
- Gincy A Lukachan
- Department of Anesthesia, Believers Church Medical College Hospital, Thiruvalla, Kerala, India
| | - Azadeh Yadollahi
- KITE - Toronto Rehabilitation Institute, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Dennis Auckley
- Division of Pulmonary, Critical Care and Sleep Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Bojan Gavrilovic
- KITE - Toronto Rehabilitation Institute, University Health Network, University of Toronto, Toronto, ON, Canada
| | - John Matelski
- Biostatistics Research Unit, University Health Network, Toronto, ON, Canada
| | - Frances Chung
- Department of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, McL 2-405, Toronto, ON, M5T 2S8, Canada
| | - Mandeep Singh
- Department of Anesthesia, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, McL 2-405, Toronto, ON, M5T 2S8, Canada.
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Chang JL, Goldberg AN, Alt JA, Alzoubaidi M, Ashbrook L, Auckley D, Ayappa I, Bakhtiar H, Barrera JE, Bartley BL, Billings ME, Boon MS, Bosschieter P, Braverman I, Brodie K, Cabrera-Muffly C, Caesar R, Cahali MB, Cai Y, Cao M, Capasso R, Caples SM, Chahine LM, Chang CP, Chang KW, Chaudhary N, Cheong CSJ, Chowdhuri S, Cistulli PA, Claman D, Collen J, Coughlin KC, Creamer J, Davis EM, Dupuy-McCauley KL, Durr ML, Dutt M, Ali ME, Elkassabany NM, Epstein LJ, Fiala JA, Freedman N, Gill K, Boyd Gillespie M, Golisch L, Gooneratne N, Gottlieb DJ, Green KK, Gulati A, Gurubhagavatula I, Hayward N, Hoff PT, Hoffmann OM, Holfinger SJ, Hsia J, Huntley C, Huoh KC, Huyett P, Inala S, Ishman SL, Jella TK, Jobanputra AM, Johnson AP, Junna MR, Kado JT, Kaffenberger TM, Kapur VK, Kezirian EJ, Khan M, Kirsch DB, Kominsky A, Kryger M, Krystal AD, Kushida CA, Kuzniar TJ, Lam DJ, Lettieri CJ, Lim DC, Lin HC, Liu SY, MacKay SG, Magalang UJ, Malhotra A, Mansukhani MP, Maurer JT, May AM, Mitchell RB, Mokhlesi B, Mullins AE, Nada EM, Naik S, Nokes B, Olson MD, Pack AI, Pang EB, Pang KP, Patil SP, Van de Perck E, Piccirillo JF, Pien GW, Piper AJ, Plawecki A, Quigg M, Ravesloot MJ, Redline S, Rotenberg BW, Ryden A, Sarmiento KF, Sbeih F, Schell AE, Schmickl CN, Schotland HM, Schwab RJ, Seo J, Shah N, Shelgikar AV, Shochat I, Soose RJ, Steele TO, Stephens E, Stepnowsky C, Strohl KP, Sutherland K, Suurna MV, Thaler E, Thapa S, Vanderveken OM, de Vries N, Weaver EM, Weir ID, Wolfe LF, Tucker Woodson B, Won CH, Xu J, Yalamanchi P, Yaremchuk K, Yeghiazarians Y, Yu JL, Zeidler M, Rosen IM. International Consensus Statement on Obstructive Sleep Apnea. Int Forum Allergy Rhinol 2023; 13:1061-1482. [PMID: 36068685 PMCID: PMC10359192 DOI: 10.1002/alr.23079] [Citation(s) in RCA: 34] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 08/12/2022] [Accepted: 08/18/2022] [Indexed: 11/08/2022]
Abstract
BACKGROUND Evaluation and interpretation of the literature on obstructive sleep apnea (OSA) allows for consolidation and determination of the key factors important for clinical management of the adult OSA patient. Toward this goal, an international collaborative of multidisciplinary experts in sleep apnea evaluation and treatment have produced the International Consensus statement on Obstructive Sleep Apnea (ICS:OSA). METHODS Using previously defined methodology, focal topics in OSA were assigned as literature review (LR), evidence-based review (EBR), or evidence-based review with recommendations (EBR-R) formats. Each topic incorporated the available and relevant evidence which was summarized and graded on study quality. Each topic and section underwent iterative review and the ICS:OSA was created and reviewed by all authors for consensus. RESULTS The ICS:OSA addresses OSA syndrome definitions, pathophysiology, epidemiology, risk factors for disease, screening methods, diagnostic testing types, multiple treatment modalities, and effects of OSA treatment on multiple OSA-associated comorbidities. Specific focus on outcomes with positive airway pressure (PAP) and surgical treatments were evaluated. CONCLUSION This review of the literature consolidates the available knowledge and identifies the limitations of the current evidence on OSA. This effort aims to create a resource for OSA evidence-based practice and identify future research needs. Knowledge gaps and research opportunities include improving the metrics of OSA disease, determining the optimal OSA screening paradigms, developing strategies for PAP adherence and longitudinal care, enhancing selection of PAP alternatives and surgery, understanding health risk outcomes, and translating evidence into individualized approaches to therapy.
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Affiliation(s)
- Jolie L. Chang
- University of California, San Francisco, California, USA
| | | | | | | | - Liza Ashbrook
- University of California, San Francisco, California, USA
| | | | - Indu Ayappa
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | | | | | - Maurits S. Boon
- Sidney Kimmel Medical Center at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Pien Bosschieter
- Academic Centre for Dentistry Amsterdam, Amsterdam, The Netherlands
| | - Itzhak Braverman
- Hillel Yaffe Medical Center, Hadera Technion, Faculty of Medicine, Hadera, Israel
| | - Kara Brodie
- University of California, San Francisco, California, USA
| | | | - Ray Caesar
- Stone Oak Orthodontics, San Antonio, Texas, USA
| | | | - Yi Cai
- University of California, San Francisco, California, USA
| | | | | | | | | | | | | | | | | | - Susmita Chowdhuri
- Wayne State University and John D. Dingell VA Medical Center, Detroit, Michigan, USA
| | - Peter A. Cistulli
- Faculty of Medicine and Health, University of Sydney, Sydney, Australia
| | - David Claman
- University of California, San Francisco, California, USA
| | - Jacob Collen
- Uniformed Services University, Bethesda, Maryland, USA
| | | | | | - Eric M. Davis
- University of Virginia, Charlottesville, Virginia, USA
| | | | | | - Mohan Dutt
- University of Michigan, Ann Arbor, Michigan, USA
| | - Mazen El Ali
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | | | | | | | - Kirat Gill
- Stanford University, Palo Alto, California, USA
| | | | - Lea Golisch
- University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | | | | | | | - Arushi Gulati
- University of California, San Francisco, California, USA
| | | | | | - Paul T. Hoff
- University of Michigan, Ann Arbor, Michigan, USA
| | - Oliver M.G. Hoffmann
- University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | | | - Jennifer Hsia
- University of Minnesota, Minneapolis, Minnesota, USA
| | - Colin Huntley
- Sidney Kimmel Medical Center at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | | | - Sanjana Inala
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | | | | | | | | | | | | | | | - Meena Khan
- Ohio State University, Columbus, Ohio, USA
| | | | - Alan Kominsky
- Cleveland Clinic Head and Neck Institute, Cleveland, Ohio, USA
| | - Meir Kryger
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | | | | | - Derek J. Lam
- Oregon Health and Science University, Portland, Oregon, USA
| | | | | | | | | | | | | | - Atul Malhotra
- University of California, San Diego, California, USA
| | | | - Joachim T. Maurer
- University Hospital Mannheim, Ruprecht-Karls-University Heidelberg, Heidelberg, Germany
| | - Anna M. May
- Case Western Reserve University, Cleveland, Ohio, USA
| | - Ron B. Mitchell
- University of Texas, Southwestern and Children’s Medical Center Dallas, Texas, USA
| | | | | | | | | | - Brandon Nokes
- University of California, San Diego, California, USA
| | | | - Allan I. Pack
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | | | | | | | | | | | | | | | - Mark Quigg
- University of Virginia, Charlottesville, Virginia, USA
| | | | - Susan Redline
- Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Armand Ryden
- Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | | | - Firas Sbeih
- Cleveland Clinic Head and Neck Institute, Cleveland, Ohio, USA
| | | | | | | | | | - Jiyeon Seo
- University of California, Los Angeles, California, USA
| | - Neomi Shah
- Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | | | - Ryan J. Soose
- University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Erika Stephens
- University of California, San Francisco, California, USA
| | | | | | | | | | - Erica Thaler
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Sritika Thapa
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Nico de Vries
- Academic Centre for Dentistry Amsterdam, Amsterdam, The Netherlands
| | | | - Ian D. Weir
- Yale School of Medicine, New Haven, Connecticut, USA
| | | | | | | | - Josie Xu
- University of Toronto, Ontario, Canada
| | | | | | | | | | | | - Ilene M. Rosen
- University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Lukachan GA, Chung F, Yadollahi A, Auckley D, Eissa M, Rahman N, McCluskey S, Singh M. Perioperative trends in neck and leg fluid volume in surgical patients: a prospective observational proof-of-concept study. Can J Anaesth 2023; 70:191-201. [PMID: 36450944 DOI: 10.1007/s12630-022-02362-6] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 08/03/2022] [Accepted: 08/03/2022] [Indexed: 12/02/2022] Open
Abstract
PURPOSE The severity of obstructive sleep apnea (OSA) may increase postoperatively. The changes in segmental fluid volume, especially neck fluid volume, may be related to increasing airway collapsibility and thus worsening of OSA in the postoperative period. Our objective was to evaluate the feasibility of performing bioelectrical impedance analysis (BIA) and to describe the trend and predictors of changes in segmental fluid volumes in patients receiving general anesthesia for noncardiac surgery. METHODS We conducted a prospective observational proof-of-concept cohort study of adult patients undergoing elective inpatient noncardiac surgery. Patients underwent a portable sleep study before surgery, and segmental fluid volumes (neck fluid volume [NFV], NFV phase angle, and leg fluid volume [LFV]) were measured using BIA at set time points: preoperative period (preop), in the postanesthesia care unit (PACU), the night following surgery at 10 pm (N 0), and the following day at 10 am (POD 1). Linear regression models were constructed to evaluate for significant predictors of overall segmental fluid changes. The variables included in the models were sex, preoperative apnea-hypopnea index (AHI), fluid balance, body mass index (BMI), cumulative opioids, and the timepoint of measurement. RESULTS Thirty-five adult patients (20/35 females, 57%) were included. For the feasibility outcome, measure of recruitment was 50/66 (76%) and two measures of protocol adherence were fluid measurements (34/39, 87%) and preoperative sleep study (35/39, 90%). There was a significant increase in NFV from preop to N 0 and in LFV from preop to PACU. Neck fluid volume also increased from PACU to N 0 and PACU to POD 1, while LFV decreased during the same intervals. The overall changes in NFV were associated with the preop AHI, BMI, and opioids after adjusting for body position and pneumoperitoneum. CONCLUSIONS This proof-of-concept study showed the feasibility and variability of segmental fluid volumes in the perioperative period using BIA. We found an increase in NFV and LFV in the immediate postoperative period in both males and females, followed by the continued rise in NFV and a simultaneous decrease in LFV, which suggest the occurrence of rostral fluid shift. Preoperative AHI, BMI, and opioids predicted the NFV changes. STUDY REGISTRATION ClinicalTrials.gov; NCT02666781, registered 25 January 2016; NCT03850041, registered 20 February 2019.
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Affiliation(s)
- Gincy A Lukachan
- Department of Anesthesia, Believers Church Medical College Hospital, Thiruvalla, Kerala, India
| | - Frances Chung
- Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, McL 2-405, Toronto, ON, M5T 2S8, Canada
| | - Azadeh Yadollahi
- KITE - Toronto Rehabilitation Institute, University Health Network, Toronto, ON, Canada
- Institute of Biomedical Engineering, University of Toronto, Toronto, ON, Canada
| | - Dennis Auckley
- Division of Pulmonary, Critical Care and Sleep Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - Mohamed Eissa
- Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, McL 2-405, Toronto, ON, M5T 2S8, Canada
- Department of Anesthesiology and Pain Management, Women's College Hospital, University of Toronto, Toronto, ON, Canada
| | - Nayeemur Rahman
- Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, McL 2-405, Toronto, ON, M5T 2S8, Canada
| | - Stuart McCluskey
- Department of Anesthesia, Toronto General Hospital, University Health Network, University of Toronto, Toronto, ON, Canada
| | - Mandeep Singh
- Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, McL 2-405, Toronto, ON, M5T 2S8, Canada.
- Department of Anesthesiology and Pain Management, Women's College Hospital, University of Toronto, Toronto, ON, Canada.
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Singh M, Tian C, Hyman JB, Siddiqui S, Auckley D, Khanna AK, Wong J, Englesakis M, Singh KP, Ramachandran SK. Level of Evidence of Guidelines for Perioperative Management of Patients With Obstructive Sleep Apnea: An Evaluation Using the Appraisal of Guidelines for Research and Evaluation II Tool. Anesth Analg 2023; 136:262-269. [PMID: 36638510 DOI: 10.1213/ane.0000000000006320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Currently, the quality of guidelines for the perioperative management of patients with obstructive sleep apnea (OSA) is unknown, leaving anesthesiologists to make perioperative management decisions with some degree of uncertainty. This study evaluated the quality of clinical practice guidelines regarding the perioperative management of patients with OSA. This study was reported in compliance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A systematic search of the MedlineALL (Ovid) database was conducted from inception to February 26, 2021, for clinical practice guidelines in the English language. Quality appraisal of guidelines was evaluated using the Appraisal of Guidelines for Research and Evaluation II (AGREE II) framework. Descriptive statistical analysis of each of the 6 domains was expressed as a percentage using the formula: (obtained score - minimum possible score)/(maximum possible score - minimum possible score). Of 192 articles identified in the search, 41 full texts were assessed for eligibility, and 10 articles were included in this review. Intraclass correlation coefficients of the AGREE II scores across the 7 evaluators for each guideline were each >0.9, suggesting that the consistency of the scores among evaluators was high. Sixty percent of recommendations were based on evidence using validated methods to grade medical literature, while the remainder were consensus based. The median and range scores of each domain were: (1) scope and purpose, 88% (60%-95%); (2) stakeholder involvement, 52% (30%-82%); (3) rigor of development, 67% (40%-90%); (4) clarity of presentation, 74% (57%-88%); (5) applicability, 46% (20%-73%); and (6) editorial independence, 67% (19%-83%). Only 4 guidelines achieved an overall score of >70%. This critical appraisal showed that many clinical practice guidelines for perioperative management of patients with OSA used validated methods to grade medical literature, such as Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) and Oxford classification, with lower scores for stakeholder involvement due to lack of engagement of patient partners and applicability domain due to lack of focus on the complete perioperative period such as postdischarge counseling. Future efforts should be directed toward establishing higher focus on the quality of evidence, stakeholder involvement, and applicability to the wider perioperative patient experience.
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Affiliation(s)
- Mandeep Singh
- From the Department of Anesthesiology and Pain Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesiology and Pain Medicine, Toronto Western & Women' College Hospitals, Toronto, Ontario, Canada.,Toronto Sleep and Pulmonary Centre, Toronto, Ontario, Canada
| | - Chenchen Tian
- From the Department of Anesthesiology and Pain Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jaime B Hyman
- Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut
| | - Shahla Siddiqui
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Dennis Auckley
- Division of Pulmonary, Sleep, and Critical Care Medicine, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Ashish K Khanna
- Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina.,Outcomes Research Consortium, Cleveland, Ohio
| | - Jean Wong
- From the Department of Anesthesiology and Pain Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesiology and Pain Medicine, Toronto Western & Women' College Hospitals, Toronto, Ontario, Canada
| | - Marina Englesakis
- From the Department of Anesthesiology and Pain Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Kawal Preet Singh
- From the Department of Anesthesiology and Pain Medicine, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Satya Krishna Ramachandran
- Department of Anesthesia, Critical Care and Pain Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Auckley D, Singh M. Protocolizing perioperative OSA screening and management: moving in the right direction. J Clin Sleep Med 2022; 18:1895-1896. [PMID: 35702018 PMCID: PMC9340586 DOI: 10.5664/jcsm.10154] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Dennis Auckley
- Professor of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH
| | - Mandeep Singh
- Department of Anesthesia, Women's College Hospital, and Toronto Western Hospital, University Health Network; University of Toronto, Toronto, ON, Canada
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Lyons MM, Gali B, Auckley D, Mokhlesi B, Myers J, Charchaflieh J, Yilmaz M, Williams L, Khan M, Card E, Gelfand B, Pilla M, Loftsgard T, Sawyer A, Matura LA, Carlucci M, Sahni A, Glaser K, Ghussain DA, Brock G, Magalang U, Pack A, Rosen I. 0363 Perceptions of the Need for Perioperative OSA Education: An Interdisciplinary and Multi-Institutional Survey. Sleep 2022. [DOI: 10.1093/sleep/zsac079.360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Advanced Practice Providers (APPs; Advanced practice registered nurses, physician assistants) and physicians-in-training (residents, fellows) receive inadequate education on obstructive sleep apnea (OSA)/perioperative OSA risks. However, they are front-line providers assessing these patients. Failure to mitigate this risk has led to significant postoperative morbidity/mortality. We assessed these providers’ perceptions to OSA/perioperative OSA training.
Methods
Surveys were sent to three provider roles, APPs, residents, and fellows, in four categories of practice at nine academic institutions between May 9-June 30, 2021. Chi-square and Fisher’s exact tests assessed association between survey responses and participant characteristics. False discovery rate adjustment accounted for multiple comparisons, threshold of q<0.05 for statistical significance. Cochran-Mantel-Haenzsel tests evaluated associations stratified by institution.
Results
2236 of 6724 (33.3%) participants responded: 48.4% APPs, 11% Fellows and 40.6% Residents. Primary category of practice included: 20.3% Anesthesiology, 8.9% Family Medicine, 34.1%, Internal Medicine (IM)/IM subspecialties, 6.7% Obstetrics/Gynecology/Gynecologic Oncology, 25.9% Surgery/Surgery subspecialties, 4.1% Other.While 93.2% of respondents believed OSA is a risk factor for perioperative complications, fewer respondents reported that they felt adequately trained to assess for OSA (50.9%) in general, with significant differences noted by provider role (range 42-70%, q=0.001) and across the categories of practice (range 12-82%, q=0.001). Even fewer felt adequately trained to assess for OSA in perioperative patients (38.2%) with significant differences noted by provider role (range 31-52%, q=0.001) and across the categories of practice (range 15-84%, q=0.001).Across all categories of practice, respondents indicated that they would like additional educational training about OSA (76.7%). This varied by clinical role (range 64-82%, q=0.003), but not categories of practice (range 73-84%, q=0.13). Furthermore, respondents indicated they also desired additional education about OSA in the perioperative patient (75.5%). This extended across all clinical roles (range 68-77%, q=0.09) and categories of practice (range 72-80%, q=0.09).
Conclusion
We found significant differences in APP and physician-in-training perceptions of the adequacy of their current training and desire for further OSA/perioperative OSA education. Our study identifies a critical gap and opportunity to improve provider understanding and patient care.
Support (If Any)
American Academy of Sleep Medicine Foundation (AASMF) award.
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Affiliation(s)
- M Melanie Lyons
- The Ohio State University Wexner Medical Center/ College of Medicine
| | | | - Dennis Auckley
- Case Western Reserve University School of Medicine/MetroHealth Medical Center
| | | | - John Myers
- The Ohio State University, Center for Biostatistics, Department of Biomedical Informatics
| | | | - Meltem Yilmaz
- Northwestern University School of Medicine/Northwestern Medicine
| | | | - Meena Khan
- The Ohio State University College of Medicine/Wexner Medical Center
| | - Elizabeth Card
- Vanderbilt University Medical Center, Nursing Research Office
| | - Brain Gelfand
- Vanderbilt University School of Medicine/Vanderbilt University Medical Center (VUMC)
| | | | | | - Amy Sawyer
- University of Pennsylvania, School of Nursing
| | | | - Melissa Carlucci
- University of Illinois Chicago College of Nursing/University of Illinois Hospital and Health Sciences System (UI Health)
| | | | | | | | - Guy Brock
- The Ohio State University Center for Biostatistics
| | - Ulysses Magalang
- The Ohio State University College of Medicine/Wexner Medical Center
| | - Allan Pack
- University of Pennsylvania Perelman School of Medicine/Penn Medicine
| | - Ilene Rosen
- University of Pennsylvania Perelman School of Medicine/Penn Medicine
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9
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Pascoe M, Bena J, Andrews ND, Auckley D, Benca R, Billings ME, Kapur VK, Iber C, Zee PC, Redline S, Rosen CL, Foldvary-Schaefer N. Dose response relationship between positive airway pressure therapy and excessive daytime sleepiness: the HomePAP study. J Clin Sleep Med 2021; 18:1027-1034. [PMID: 34870587 DOI: 10.5664/jcsm.9792] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 11/13/2022]
Abstract
STUDY OBJECTIVES Clinical benefits of PAP therapy for OSA are assumed to require adherent PAP usage, as defined by CMS as ≥ 4 hours of use ≥ 70% of nights. However, this is based on early data and does not necessarily capture improvements at subthreshold adherence. We explored dose-response relationships between PAP adherence measures and EDS from the HomePAP RCT. METHODS Participants ≥18 years with apnea hypopnea index ≥ 15 and baseline sleepiness (Epworth Sleepiness Scale (ESS) ≥ 12) received PAP therapy. Data were collected at baseline, 1-month, and 3-months follow-up. Regression models and receiver operating characteristic curves evaluated PAP measures as predictors of ESS change and normalization (ESS < 10). RESULTS In 119 participants (age 49.4 ± 12.6 years, 66.4% male, 72.3% white), > 50% were PAP non-adherent per CMS criteria at 3 months. Percent of nights with PAP use ≥ 4 hours predicted ESS change (p = 0.023), but not when controlling for AHI. Percent of nights with ≥ 4 hours and average PAP use provided the best discrimination for predicting ESS normalization; each 10% increase in PAP use ≥ 4 hours increased the odds of ESS normalization by 22% (p = 0.007); those using PAP ≥ 4 hours had nearly 3-fold greater odds of ESS normalization (p = 0.025). At least 4 hours and 70% of nights provided the best balance between specificity (0.50) and sensitivity (0.73). CONCLUSIONS Although sub-adherent PAP usage may still confer some benefit for OSA patients, adherence to current criteria confers the highest likelihood for ESS change and normalization. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Title: Portable Monitoring for Diagnosis and Management of Sleep Apnea (HomePAP); Identifier: NCT00642486; URL: http://clinicaltrials.gov/show/NCT00642486.
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Affiliation(s)
- Maeve Pascoe
- Cleveland Clinic Sleep Disorders Center, Cleveland, OH
| | - James Bena
- Cleveland Clinic Sleep Disorders Center, Cleveland, OH
| | | | - Dennis Auckley
- MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland OH
| | - Ruth Benca
- University of California Irvine, Irvine, CA
| | | | - Vishesh K Kapur
- Harborview Medical Center, University of Washington, Seattle, WA
| | | | - Phyllis C Zee
- Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Susan Redline
- Brigham and Women's Hospital and Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Carol L Rosen
- Case Western Reserve University School of Medicine, Cleveland, OH
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10
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Eissa MS, Auckley D, Singh M. Perioperative implications of positive airway pressure device recall by a major manufacturer. J Clin Anesth 2021; 78:110523. [PMID: 34593276 DOI: 10.1016/j.jclinane.2021.110523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 09/12/2021] [Accepted: 09/17/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Mohamed S Eissa
- Department of Anesthesiology and Pain Management, Women's College Hospital, Toronto, Ontario, Canada; Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada; Department of Anesthesia and Pain Management, Ain Shams University, Cairo, Egypt.
| | - Dennis Auckley
- Division of Pulmonary, Critical Care and Sleep Medicine, MetroHealth Medical Center, Case Western Reserve University, School of Medicine, Cleveland, OH, United States of America.
| | - Mandeep Singh
- Department of Anesthesiology and Pain Management, Women's College Hospital, Toronto, Ontario, Canada; Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.
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11
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Khanna AK, Jungquist CR, Buhre W, Soto R, Di Piazza F, Saager L, Bergese SD, Morimatsu H, Uezono S, Lee S, Ti LK, Urman RD, McIntyre R, Tornero C, Dahan A, Weingarten TN, Wittmann M, Auckley D, Brazzi L, Le Guen M, Schramm F, Overdyk FJ. Modeling the Cost Savings of Continuous Pulse Oximetry and Capnography Monitoring of United States General Care Floor Patients Receiving Opioids Based on the PRODIGY Trial. Adv Ther 2021; 38:3745-3759. [PMID: 34031858 PMCID: PMC8143066 DOI: 10.1007/s12325-021-01779-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Accepted: 05/06/2021] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Despite the high incidence of respiratory depression on the general care floor and evidence that continuous monitoring improves patient outcomes, the cost-benefit of continuous pulse oximetry and capnography monitoring of general care floor patients remains unknown. This study modeled the cost and length of stay savings, investment break-even point, and likelihood of cost savings for continuous pulse oximetry and capnography monitoring of general care floor patients at risk for respiratory depression. METHODS A decision tree model was created to compare intermittent pulse oximetry versus continuous pulse oximetry and capnography monitoring. The model utilized costs and outcomes from the PRediction of Opioid-induced respiratory Depression In patients monitored by capnoGraphY (PRODIGY) trial, and was applied to a modeled cohort of 2447 patients receiving opioids per median-sized United States general care floor annually. RESULTS Continuous pulse oximetry and capnography monitoring of high-risk patients is projected to reduce annual hospital cost by $535,531 and cumulative patient length of stay by 103 days. A 1.5% reduction in respiratory depression would achieve a break-even investment point and justify the investment cost. The probability of cost saving is ≥ 80% if respiratory depression is decreased by ≥ 17%. Expansion of continuous monitoring to high- and intermediate-risk patients, or to all patients, is projected to reach a break-even point when respiratory depression is reduced by 2.5% and 3.5%, respectively, with a ≥ 80% probability of cost savings when respiratory depression decreases by ≥ 27% and ≥ 31%, respectively. CONCLUSION Compared to intermittent pulse oximetry, continuous pulse oximetry and capnography monitoring of general care floor patients receiving opioids has a high chance of being cost-effective. TRIAL REGISTRATION www.clinicaltrials.gov , Registration ID: NCT02811302.
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12
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Khalid F, Ayache M, Auckley D. The differential impact of respiratory event scoring criteria on CPAP eligibility in women and men. J Clin Sleep Med 2021; 17:2409-2414. [PMID: 34170229 DOI: 10.5664/jcsm.9448] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Obstructive sleep apnea (OSA) is more prevalent and severe in men than women. The American Academy of Sleep Medicine (AASM) offers 2 definitions for scoring hypopneas: "acceptable" = associated with a >4% oxygen desaturation, adopted by Center for Medicare and Medicaid Services (CMS), and "recommended" = associated with a >3% oxygen desaturation and / or an arousal. We hypothesized that CMS versus AASM scoring criteria would differentially impact continuous positive airway pressure (CPAP) eligibility in women and men. METHODS We conducted a retrospective review of adult diagnostic in-lab polysomnography (PSG) at an urban academic institution. All PSGs were scored by both CMS and AASM scoring criteria, and an analysis by sex was performed that took into account demographics and other PSG variables. RESULTS Of 969 PSGs reviewed, 674 (69.6%) were in women. Women were younger (51.5 vs. 53.3 y/o) and had a higher body mass index (BMI 38.6 kg/m2 vs. 33.8 kg/m2) but had similar Epworth Sleepiness Scale scores when compared to men. The odds of an AASM AHI > 5 being missed by CMS scoring in women was 1.89 (95% CI: 1.40-2.53; p<0.001) compared to men and increased to 6.87 among women 40-60 years of age with a BMI≥40 kg/m2. After controlling for age, BMI, % REM sleep and mean oxygen saturation, the sex effect remained significant (OR 1.87; 95% CI: 1.36-2.58; p<0.001). CONCLUSIONS CMS scoring criteria imparts a sex bias towards women potentially resulting in denial of therapy to symptomatic women with OSA. Larger, prospective cohort studies are needed to confirm these findings.
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Affiliation(s)
- Faiza Khalid
- Division of Pulmonary, Critical Care and Sleep Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH
| | - Mirna Ayache
- Division of Pulmonary, Critical Care and Sleep Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH
| | - Dennis Auckley
- Division of Pulmonary, Critical Care and Sleep Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH
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13
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Berezin L, Nagappa M, Wong J, Clivatti J, Singh M, Auckley D, Charchaflieh JG, Jonsson Fagerlund M, Gali B, Joshi GP, Overdyk FJ, Margarson M, Mokhlesi B, Moon T, Ramachandran SK, Ryan CM, Schumann R, Weingarten TN, Won CHJ, Chung F. Identification of Sleep Medicine and Anesthesia Core Topics for Anesthesia Residency: A Modified Delphi Technique Survey. Anesth Analg 2021; 132:1223-1230. [PMID: 33857964 DOI: 10.1213/ane.0000000000005446] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Sleep disorders affect up to 25% of the general population and are associated with increased risk of adverse perioperative events. The key sleep medicine topics that are most important for the practice of anesthesiology have not been well-defined. The objective of this study was to determine the high-priority sleep medicine topics that should be included in the education of anesthesia residents based on the insight of experts in the fields of anesthesia and sleep medicine. METHODS We conducted a prospective cross-sectional survey of experts in the fields of sleep medicine and anesthesia based on the Delphi technique to establish consensus on the sleep medicine topics that should be incorporated into anesthesia residency curricula. Consensus for inclusion of a topic was defined as >80% of all experts selecting "agree" or "strongly agree" on a 5-point Likert scale. Responses to the survey questions were analyzed with descriptive statistical methods and presented as percentages or weighted mean values with standard deviations (SD) for Likert scale data. RESULTS The topics that were found to have 100% agreement among experts were the influence of opioids and anesthetics on control of breathing and upper airway obstruction; potential interactions of wake-promoting/hypnotic medications with anesthetic agents; effects of sleep and anesthesia on upper airway patency; and anesthetic management of sleep apnea. Less than 80% agreement was found for topics on the anesthetic implications of other sleep disorders and future pathways in sleep medicine and anesthesia. CONCLUSIONS We identify key topics of sleep medicine that can be included in the future design of anesthesia residency training curricula.
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Affiliation(s)
- Linor Berezin
- From the Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Mahesh Nagappa
- Department of Anesthesia and Perioperative Medicine, London Health Sciences Centre and St. Joseph Health Care, Western University, London, Ontario, Canada
| | - Jean Wong
- From the Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesiology and Pain Medicine, Women's College Hospital, Toronto, Ontario, Canada
| | - Jefferson Clivatti
- Department of Anesthesia, Ajax Pickering Hospital, Lakeridge Health, Ajax, Ontario, Canada
| | - Mandeep Singh
- From the Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Dennis Auckley
- Division of Pulmonary, Critical Care and Sleep Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Jean G Charchaflieh
- Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut
| | - Malin Jonsson Fagerlund
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Solna, Sweden.,Department of Physiology and Pharmacology, Section for Anesthesiology and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Bhargavi Gali
- Division of Critical Care, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Girish P Joshi
- Division of Critical Care, Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Frank J Overdyk
- Trident Anesthesia Group, Trident Medical Center, Charleston, South Carolina
| | - Michael Margarson
- Department of Anesthesia, St Richard's Hospital, Chichester, United Kingdom
| | - Babak Mokhlesi
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Tiffany Moon
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Satya K Ramachandran
- Department of Anaesthesia, Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Clodagh M Ryan
- Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Roman Schumann
- Departments of Anesthesiology and Surgery, Tufts University School of Medicine, Boston, Massachusetts.,Department of Anesthesiology and Critical Care, Veterans Affairs Boston Healthcare System, Boston, Massachusetts
| | - Toby N Weingarten
- Department of Anesthesia and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Christine H J Won
- Section of Pulmonary, Critical Care and Sleep Medicine, Yale University School of Medicine, New Haven, Connecticut.,Veterans Affair Connecticut Healthcare System, New Haven, Connecticut
| | - Frances Chung
- From the Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada
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14
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Abstract
Obstructive sleep apnea (OSA) has been shown to increase risk of adverse perioperative events. More recently, investigators have begun to examine other common sleep disorders to assess how they may be impacted by the perioperative environment, as well as influence postoperative outcomes. There are a number of mechanisms by which such common sleep disorders (eg, insomnia, restless legs syndrome, narcolepsy, and parasomnias) may have consequences in the perioperative setting, both related to the underlying pathophysiology of the diseases as well as their treatments. This review will highlight the current state of the literature and offer recommendations for management of these conditions during the perioperative journey.
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Affiliation(s)
- Shelley Hershner
- From the Department of Neurology, University of Michigan, Ann Arbor, Michigan
| | - Dennis Auckley
- Division of Pulmonary, Critical Care and Sleep Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
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15
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Abstract
There is common ground between the specialties of anesthesiology and sleep medicine. Traditional sleep medicine curriculum for anesthesiology trainees has revolved around the discussion of obstructive sleep apnea (OSA) and its perioperative management. However, it is time to include a broader scope of sleep medicine-related topics that overlap these specialties into the core anesthesia residency curriculum. Five main core competency domains are proposed, including SLeep physiology; Evaluation of sleep health; Evaluation for sleep disorders and clinical implications; Professional and academic roles; and WELLness (SLEEP WELL). The range of topics include not only the basics of the physiology of sleep and sleep-disordered breathing (eg, OSA and central sleep apnea) but also insomnia, sleep-related movement disorders (eg, restless legs syndrome), and disorders of daytime hypersomnolence (eg, narcolepsy) in the perioperative and chronic pain settings. Awareness of these topics is relevant to the scope of knowledge of anesthesiologists as perioperative physicians as well as to optimal sleep health and physician wellness and increase consideration among current anesthesiology trainees for the value of dual credentialing in both these specialties.
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Affiliation(s)
- Mandeep Singh
- From the Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesiology and Pain Medicine, Women's College Hospital, and Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada.,Toronto Sleep and Pulmonary Centre, Toronto, Ontario, Canada
| | - Bhargavi Gali
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Mark Levine
- From the Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada.,Department of Anesthesiology and Pain Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kingman Strohl
- Division of Pulmonary, Critical Care and Sleep Medicine, University Hospitals and
| | - Dennis Auckley
- Division of Pulmonary, Critical Care and Sleep Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
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16
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Suen C, Wong J, Warsame K, Subramani Y, Panzarella T, Waseem R, Auckley D, Chaudhry R, Islam S, Chung F. Perioperative adherence to continuous positive airway pressure and its effect on postoperative nocturnal hypoxemia in obstructive sleep apnea patients: a prospective cohort study. BMC Anesthesiol 2021; 21:142. [PMID: 33975540 PMCID: PMC8111893 DOI: 10.1186/s12871-021-01371-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Accepted: 04/15/2021] [Indexed: 01/25/2023] Open
Abstract
Background Although continuous positive airway pressure (CPAP) is the first line treatment for obstructive sleep apnea (OSA) patients, the perioperative adherence rate is unclear. The objective of this study was to determine the perioperative adherence rate of patients with OSA with a CPAP prescription and the effect of adherence on nocturnal oxygen saturation. Methods This prospective cohort study included adult surgical patients with a diagnosis of OSA with CPAP prescription undergoing elective non-cardiac surgery. Patients were divided into CPAP adherent and non-adherent groups based on duration of usage (≥ 4 h/night). Overnight oximetry was performed preoperatively and on postoperative night 1 and 2 (N1, N2). The primary outcome was adherence rate and the secondary outcome was nocturnal oxygen saturation. Results One hundred and thirty-two patients completed the study. CPAP adherence was 61% preoperatively, 58% on postoperative N1, and 59% on N2. Forty-nine percent were consistently CPAP adherent pre- and postoperatively. Using a linear fixed effects regression, oxygen desaturation index (ODI) was significantly improved by CPAP adherence (p = 0.0011). The interaction term CPAP x N1 was significant (p = 0.0015), suggesting that the effect of CPAP adherence varied on N1 vs preoperatively. There was no benefit of CPAP adherence on postoperative mean SpO2, minimum SpO2, and percentage of sleep duration with SpO2 < 90%. Use of supplemental oxygen therapy was much lower in the CPAP adherent group vs non-adherent group (9.8% vs 46.5%, p < 0.001). Conclusions Among patients with a preoperative CPAP prescription, approximately 50% were consistently adherent. CPAP adherence was associated with improved preoperative ODI and the benefit was maintained on N1. These modest effects may be underestimated by a higher severity of OSA in the CPAP adherent group and a higher rate of oxygen supplementation in the non-adherent group. Trial registration ClinicalTrials.Gov registry (NCT02796846). Supplementary Information The online version contains supplementary material available at 10.1186/s12871-021-01371-0.
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Affiliation(s)
- Colin Suen
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, MCL 2-405, 399 Bathurst St., Toronto, ON, M5T2S8, Canada
| | - Jean Wong
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, MCL 2-405, 399 Bathurst St., Toronto, ON, M5T2S8, Canada.,Department of Anesthesia and Pain Management, Women's College Hospital, University of Toronto, Toronto, ON, Canada
| | - Kahiye Warsame
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, MCL 2-405, 399 Bathurst St., Toronto, ON, M5T2S8, Canada.,Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Yamini Subramani
- Department of Anesthesia and Perioperative Medicine, London Health Science Centre, St. Joseph Health Care, Western University, London, ON, Canada
| | - Tony Panzarella
- Division of Biostatistics, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Rida Waseem
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, MCL 2-405, 399 Bathurst St., Toronto, ON, M5T2S8, Canada
| | - Dennis Auckley
- Division of Pulmonary, Critical Care and Sleep Medicine, MetroHealth Medical Center, Case Western Reserve University, School of Medicine, Cleveland, OH, USA
| | - Rabail Chaudhry
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, MCL 2-405, 399 Bathurst St., Toronto, ON, M5T2S8, Canada
| | - Sazzadul Islam
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, MCL 2-405, 399 Bathurst St., Toronto, ON, M5T2S8, Canada
| | - Frances Chung
- Department of Anesthesia and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, MCL 2-405, 399 Bathurst St., Toronto, ON, M5T2S8, Canada.
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17
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Singh M, Mejia JM, Auckley D, Abdallah F, Li C, Kumar V, Englesakis M, Brull R. Correction to: The impact of unilateral diaphragmatic paralysis on sleepdisordered breathing: a scoping review. Can J Anaesth 2021; 68:1305. [PMID: 33829392 DOI: 10.1007/s12630-021-01981-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Affiliation(s)
- Mandeep Singh
- Department of Anesthesiology and Pain Management, Women's College Hospital, Toronto, ON, Canada. .,Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, McL 2-405, Toronto, ON, M5T 2S8, Canada.
| | - Jorge M Mejia
- Department of Anesthesiology and Pain Management, Women's College Hospital, Toronto, ON, Canada.,Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, McL 2-405, Toronto, ON, M5T 2S8, Canada
| | - Dennis Auckley
- Division of Pulmonary, Critical Care and Sleep Medicine, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Faraj Abdallah
- Department of Anesthesia, University of Ottawa, Ottawa, ON, Canada
| | - Christopher Li
- Department of Respirology, St. Michael's Hospital, Unity Health, Toronto, ON, Canada
| | - Vivek Kumar
- Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, McL 2-405, Toronto, ON, M5T 2S8, Canada
| | - Marina Englesakis
- Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, McL 2-405, Toronto, ON, M5T 2S8, Canada
| | - Richard Brull
- Department of Anesthesiology and Pain Management, Women's College Hospital, Toronto, ON, Canada.,Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, McL 2-405, Toronto, ON, M5T 2S8, Canada
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18
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Singh M, Mejia JM, Auckley D, Abdallah F, Li C, Kumar V, Englesakis M, Brull R. [The impact of unilateral diaphragmatic paralysis on sleep-disordered breathing: a scoping review]. Can J Anaesth 2021; 68:1064-1076. [PMID: 33725316 DOI: 10.1007/s12630-021-01970-y] [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] [Received: 07/05/2020] [Revised: 01/16/2021] [Accepted: 01/18/2021] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Unilateral diaphragm paralysis (UDP) may potentially worsen sleep-disordered breathing (SDB). Unilateral diaphragm paralysis has been associated with proximal brachial plexus blockade, such as interscalene and supraclavicular block. The impact of UDP in patients with SDB is not known in this context. The objectives of this scoping review were to explore the associations between UDP and worsening SDB severity, oxygenation, and pulmonary function. METHODS A systematic search was developed, peer-reviewed, and applied to Embase, Medline, CINAHL, and Cochrane databases to include studies involving adult patients (≥ 18 yr) with SDB, where the effects of UDP on SDB severity, oxygenation, and pulmonary function were examined. RESULTS Six studies (n = 100 patients) with UDP and SDB were included. The sample population was derived exclusively from respirology-sleep clinics, and none were surgical patients. Compared with control (no UDP), UDP was associated with an increased respiratory disturbance index, most pronounced during rapid eye movement (REM) sleep and supine sleep. Supine and REM sleep were associated with obstructive and mixed (both obstructive and central) events, respectively. Compared with control, UDP was associated with a lower mean and minimum oxygen saturation and arterial oxygen tension during all sleep stages and in all body positions. The majority of UDP patients were found to have clinically significant reductions in mean forced expiratory volume in one second and forced vital capacity values, consistent with restrictive ventilatory pattern. CONCLUSION We observed an association between UDP and increasing SDB severity, particularly during REM sleep and while sleeping in the supine position. Although we identified weaknesses in study design and lack of perioperative data, anesthesiologists should be aware of this association when considering proximal brachial plexus blockade in patients with SDB.
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Affiliation(s)
- Mandeep Singh
- Department of Anesthesiology and Pain Management, Women's College Hospital, Toronto, ON, Canada. .,Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, McL 2-405, Toronto, ON, M5T 2S8, Canada.
| | - Jorge M Mejia
- Department of Anesthesiology and Pain Management, Women's College Hospital, Toronto, ON, Canada.,Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, McL 2-405, Toronto, ON, M5T 2S8, Canada
| | - Dennis Auckley
- Division of Pulmonary, Critical Care and Sleep Medicine, MetroHealth Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Faraj Abdallah
- Department of Anesthesia, University of Ottawa, Ottawa, ON, Canada
| | - Christopher Li
- Department of Respirology, St. Michael's Hospital, Unity Health, Toronto, ON, Canada
| | - Vivek Kumar
- Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, McL 2-405, Toronto, ON, M5T 2S8, Canada
| | - Marina Englesakis
- Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, McL 2-405, Toronto, ON, M5T 2S8, Canada
| | - Richard Brull
- Department of Anesthesiology and Pain Management, Women's College Hospital, Toronto, ON, Canada.,Department of Anesthesiology and Pain Management, Toronto Western Hospital, University Health Network, University of Toronto, 399 Bathurst Street, McL 2-405, Toronto, ON, M5T 2S8, Canada
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19
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Khanna AK, Bergese SD, Jungquist CR, Morimatsu H, Uezono S, Lee S, Ti LK, Urman RD, McIntyre R, Tornero C, Dahan A, Saager L, Weingarten TN, Wittmann M, Auckley D, Brazzi L, Le Guen M, Soto R, Schramm F, Ayad S, Kaw R, Di Stefano P, Sessler DI, Uribe A, Moll V, Dempsey SJ, Buhre W, Overdyk FJ. Prediction of Opioid-Induced Respiratory Depression on Inpatient Wards Using Continuous Capnography and Oximetry: An International Prospective, Observational Trial. Anesth Analg 2020; 131:1012-1024. [PMID: 32925318 PMCID: PMC7467153 DOI: 10.1213/ane.0000000000004788] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/24/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Opioid-related adverse events are a serious problem in hospitalized patients. Little is known about patients who are likely to experience opioid-induced respiratory depression events on the general care floor and may benefit from improved monitoring and early intervention. The trial objective was to derive and validate a risk prediction tool for respiratory depression in patients receiving opioids, as detected by continuous pulse oximetry and capnography monitoring. METHODS PRediction of Opioid-induced respiratory Depression In patients monitored by capnoGraphY (PRODIGY) was a prospective, observational trial of blinded continuous capnography and oximetry conducted at 16 sites in the United States, Europe, and Asia. Vital signs were intermittently monitored per standard of care. A total of 1335 patients receiving parenteral opioids and continuously monitored on the general care floor were included in the analysis. A respiratory depression episode was defined as respiratory rate ≤5 breaths/min (bpm), oxygen saturation ≤85%, or end-tidal carbon dioxide ≤15 or ≥60 mm Hg for ≥3 minutes; apnea episode lasting >30 seconds; or any respiratory opioid-related adverse event. A risk prediction tool was derived using a multivariable logistic regression model of 46 a priori defined risk factors with stepwise selection and was internally validated by bootstrapping. RESULTS One or more respiratory depression episodes were detected in 614 (46%) of 1335 general care floor patients (43% male; mean age, 58 ± 14 years) continuously monitored for a median of 24 hours (interquartile range [IQR], 17-26). A multivariable respiratory depression prediction model with area under the curve of 0.740 was developed using 5 independent variables: age ≥60 (in decades), sex, opioid naivety, sleep disorders, and chronic heart failure. The PRODIGY risk prediction tool showed significant separation between patients with and without respiratory depression (P < .001) and an odds ratio of 6.07 (95% confidence interval [CI], 4.44-8.30; P < .001) between the high- and low-risk groups. Compared to patients without respiratory depression episodes, mean hospital length of stay was 3 days longer in patients with ≥1 respiratory depression episode (10.5 ± 10.8 vs 7.7 ± 7.8 days; P < .0001) identified using continuous oximetry and capnography monitoring. CONCLUSIONS A PRODIGY risk prediction model, derived from continuous oximetry and capnography, accurately predicts respiratory depression episodes in patients receiving opioids on the general care floor. Implementation of the PRODIGY score to determine the need for continuous monitoring may be a first step to reduce the incidence and consequences of respiratory compromise in patients receiving opioids on the general care floor.
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Affiliation(s)
- Ashish K. Khanna
- From the Department of Anesthesiology, Section on Critical Care Medicine, Wake Forest School of Medicine, Winston-Salem, North Carolina
- Outcomes Research Consortium, Cleveland, Ohio
| | - Sergio D. Bergese
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, Ohio
- Department of Anesthesiology, Stony Brook University School of Medicine, Stony Brook, New York
| | | | - Hiroshi Morimatsu
- Department of Anesthesiology and Resuscitology, Okayama University Hospital, Okayama, Japan
| | | | - Simon Lee
- Department of Anesthesiology, Emory University, Atlanta, Georgia
| | - Lian Kah Ti
- Department of Anaesthesia, National University of Singapore, Singapore
| | - Richard D. Urman
- Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Robert McIntyre
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Carlos Tornero
- Department of Anesthesiology, Resuscitation and Pain Therapeutics, Hospital Clinico Universitario de Valencia, Valencia, Spain
| | - Albert Dahan
- Department of Anesthesiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Leif Saager
- Department of Anesthesiology, University of Michigan Medical School, Ann Arbor, Michigan
- Klinik für Anästhesiologie, Universitätsmedizin Göttingen, Göttingen, Germany
| | - Toby N. Weingarten
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Maria Wittmann
- Department of Anaesthesiology, University Hospital Bonn, Bonn, Germany
| | - Dennis Auckley
- Division of Pulmonary, Critical Care, and Sleep Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Luca Brazzi
- Department of Anesthesia, Intensive Care and Emergency, University of Turin, Turin, Italy
| | - Morgan Le Guen
- Department of Anaesthesiology, Hôpital Foch, Suresnes, France
| | - Roy Soto
- Department of Anesthesiology, Beaumont Hospital, Royal Oak, Michigan
| | - Frank Schramm
- Department of Anesthesiology, Providence Regional Medical Center, Everett, Washington
| | - Sabry Ayad
- Cleveland Clinic Foundation, Outcomes Research Consortium, Cleveland, Ohio
| | - Roop Kaw
- Cleveland Clinic Foundation, Outcomes Research Consortium, Cleveland, Ohio
| | - Paola Di Stefano
- Medtronic Core Clinical Solutions, Study and Scientific Solutions, Rome, Italy
| | - Daniel I. Sessler
- Department of Outcomes Research, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio
| | - Alberto Uribe
- Department of Anesthesiology, The Ohio State University Medical Center, Columbus, Ohio
| | - Vanessa Moll
- Department of Anesthesiology, Emory University, Atlanta, Georgia
| | - Susan J. Dempsey
- Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado
- University of California, Los Angeles, School of Nursing, Los Angeles, California
| | - Wolfgang Buhre
- Department of Anesthesiology, University Medical Center, Maastricht, the Netherlands
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20
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Bolden N, Posner KL, Domino KB, Auckley D, Benumof JL, Herway ST, Hillman D, Mincer SL, Overdyk F, Samuels DJ, Warner LL, Weingarten TN, Chung F. Postoperative Critical Events Associated With Obstructive Sleep Apnea: Results From the Society of Anesthesia and Sleep Medicine Obstructive Sleep Apnea Registry. Anesth Analg 2020; 131:1032-1041. [PMID: 32925320 PMCID: PMC7659468 DOI: 10.1213/ane.0000000000005005] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Obstructive sleep apnea (OSA) patients are at increased risk for pulmonary and cardiovascular complications; perioperative mortality risk is unclear. This report analyzes cases submitted to the OSA Death and Near Miss Registry, focusing on factors associated with poor outcomes after an OSA-related event. We hypothesized that more severe outcomes would be associated with OSA severity, less intense monitoring, and higher cumulative opioid doses. METHODS Inclusion criteria were age ≥18 years, OSA diagnosed or suspected, event related to OSA, and event occurrence 1992 or later and <30 days postoperatively. Factors associated with death or brain damage versus other critical events were analyzed by tests of association and odds ratios (OR; 95% confidence intervals [CIs]). RESULTS Sixty-six cases met inclusion criteria with known OSA diagnosed in 55 (83%). Patients were middle aged (mean = 53, standard deviation [SD] = 15 years), American Society of Anesthesiologists (ASA) III (59%, n = 38), and obese (mean body mass index [BMI] = 38, SD = 9 kg/m); most had inpatient (80%, n = 51) and elective (90%, n = 56) procedures with general anesthesia (88%, n = 58). Most events occurred on the ward (56%, n = 37), and 14 (21%) occurred at home. Most events (76%, n = 50) occurred within 24 hours of anesthesia end. Ninety-seven percent (n = 64) received opioids within the 24 hours before the event, and two-thirds (41 of 62) also received sedatives. Positive airway pressure devices and/or supplemental oxygen were in use at the time of critical events in 7.5% and 52% of cases, respectively. Sixty-five percent (n = 43) of patients died or had brain damage; 35% (n = 23) experienced other critical events. Continuous central respiratory monitoring was in use for 3 of 43 (7%) of cases where death or brain damage resulted. Death or brain damage was (1) less common when the event was witnessed than unwitnessed (OR = 0.036; 95% CI, 0.007-0.181; P < .001); (2) less common with supplemental oxygen in place (OR = 0.227; 95% CI, 0.070-0.740; P = .011); (3) less common with respiratory monitoring versus no monitoring (OR = 0.109; 95% CI, 0.031-0.384; P < .001); and (4) more common in patients who received both opioids and sedatives than opioids alone (OR = 4.133; 95% CI, 1.348-12.672; P = .011). No evidence for an association was observed between outcomes and OSA severity or cumulative opioid dose. CONCLUSIONS Death and brain damage were more likely to occur with unwitnessed events, no supplemental oxygen, lack of respiratory monitoring, and coadministration of opioids and sedatives. It is important that efforts be directed at providing more effective monitoring for OSA patients following surgery, and clinicians consider the potentially dangerous effects of opioids and sedatives-especially when combined-when managing OSA patients postoperatively.
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Affiliation(s)
- Norman Bolden
- Department of Anesthesiology and Pain Management, MetroHealth Medical Center, Cleveland, OH, USA
| | - Karen L. Posner
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Karen B Domino
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Dennis Auckley
- Department of Pulmonary, Sleep, and Critical Care, MetroHealth Medical Center, Cleveland, OH, USA
| | - Jonathan L Benumof
- Department of Anesthesiology, University of California San Diego Medical Center, San Diego, CA, USA
| | - Seth T. Herway
- Department of Anesthesiology, Mountain West Anesthesia, St George UT, USA
| | - David Hillman
- Centre for Sleep Science, School of Human Sciences, University of Western Australia, Perth, Western Australia.”
| | - Shawn L. Mincer
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Frank Overdyk
- Department of Anesthesiology, Roper St Francis Health System, Charleston, SC, USA
| | - David J. Samuels
- Department of Anesthesiology, Tampa General Hospital, Tampa, FL, USA
| | | | | | - Frances Chung
- Department of Anesthesia and Pain Medicine, University Health Network, University of Toronto, Toronto, ON, Canada
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21
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Hershner S, Kakkar R, Chung F, Singh M, Wong J, Auckley D. Narcolepsy, Anesthesia, and Sedation: A Survey of the Perioperative Experience of Patients With Narcolepsy. Anesth Analg 2020; 129:1374-1380. [PMID: 30540615 DOI: 10.1213/ane.0000000000003954] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Patients with narcolepsy may be at increased perioperative risk due to the interactions among anesthesia, narcolepsy, and narcolepsy medications. This study sought to determine the perioperative experience of narcoleptic patients undergoing anesthesia or sedation, the frequency of perioperative counseling, and self-reported surgical complications. METHODS A 22-question survey was developed by expert consensus and distributed by the Narcolepsy Network. Recruitment was via the Narcolepsy Network's list-serve and a Facebook link to the survey. One thousand and twenty respondents reported a diagnosis of narcolepsy and 1 or more procedures under anesthesia or sedation. Descriptive, comparative statistics and logistic regression were utilized. RESULTS Respondents were mostly women (79.5%) and Caucasian (84.9%), with a mean age of 45 ± 16 years. Most respondents did not receive counseling regarding the possibility of increased sleepiness (70%), cataplexy (90%), or drowsy driving (59%) postanesthesia. More than half of respondents reported adverse events (medication withdrawal symptoms, inadequate pain relief, increased cataplexy). Subjects with cataplexy more frequently reported surgical complications (70% vs 31%; P = .03) and medication withdrawal symptoms (stimulant medications: odds ratio, 3.0 [95% CI, 1.9, 3.06]; P > .001 and antidepressant medications: odds ratio, 6.5 [95% CI, 2.1-19.5]; P = .001). Of the total sample, 18% indicated surgical complications. Undergoing 5 or more separate surgeries or procedures was associated with a 2-fold increase in self-reported complications (odds ratio, 2.2 [95% CI, 1.3-3.4]; P = .001), difficulty waking (odds ratio, 2.1 [95% CI, 1.45-3.06]; P = .001), and inadequate pain relief (odds ratio, 1.77 [95% CI, 1.01-3.13]; P < .05). CONCLUSIONS Most narcoleptic patients report not receiving counseling regarding potential worsening of narcolepsy symptoms postanesthesia or an increased risk of drowsy driving. Enhanced education of perioperative providers about potential narcolepsy-related issues is essential. Respondents frequently self-report adverse events in the perioperative period. Future studies should clarify the perioperative risk associated with narcolepsy to optimize the care and safety of narcoleptic patients.
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Affiliation(s)
- Shelley Hershner
- From the Department of Neurology, University of Michigan, Ann Arbor, Michigan
| | - Rahul Kakkar
- Narcolepsy Network Inc, North Kingstown, Rhode Island.,Prana Health, Doral, Florida
| | - Frances Chung
- Department of Anesthesia, University Health Network - University of Toronto, Toronto, Ontario, Canada
| | - Mandeep Singh
- Department of Anesthesia, University Health Network - University of Toronto, Toronto, Ontario, Canada.,Toronto Sleep and Pulmonary Centre, Toronto, Ontario, Canada
| | - Jean Wong
- Department of Anesthesia, University Health Network - University of Toronto, Toronto, Ontario, Canada
| | - Dennis Auckley
- Division of Pulmonary, Critical Care and Sleep Medicine, MetroHealth Medical Center, Cleveland, Ohio
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22
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Hershner S, Dauvilliers Y, Chung F, Singh M, Wong J, Gali B, Kakkar R, Mignot E, Thorpy M, Auckley D. Knowledge Gaps in the Perioperative Management of Adults With Narcolepsy: A Call for Further Research. Anesth Analg 2020; 129:204-211. [PMID: 30882519 DOI: 10.1213/ane.0000000000004088] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
There is increasing awareness that sleep disorders may be associated with increased perioperative risk. The Society of Anesthesia and Sleep Medicine created the Narcolepsy Perioperative Task Force: (1) to investigate the current state of knowledge of the perioperative risk for patients with narcolepsy, (2) to determine the viability of developing perioperative guidelines for the management of patients with narcolepsy, and (3) to delineate future research goals and clinically relevant outcomes. The Narcolepsy Perioperative Task Force established that there is evidence for increased perioperative risk in patients with narcolepsy; however, this evidence is sparse and based on case reviews, case series, and retrospective reviews. Mechanistically, there are a number of potential mechanisms by which patients with narcolepsy could be at increased risk for perioperative complications. These include aggravation of the disease itself, dysautonomia, narcolepsy-related medications, anesthesia interactions, and withdrawal of narcolepsy-related medications. At this time, there is inadequate research to develop an expert consensus or guidelines for the perioperative management of patients with narcolepsy. The paucity of available literature highlights the critical need to determine if patients with narcolepsy are at an increased perioperative risk and to establish appropriate research protocols and clearly delineated patient-centered outcomes. There is a real need for collaborative research among sleep medicine specialists, surgeons, anesthesiologists, and perioperative providers. This future research will become the foundation for the development of guidelines, or at a minimum, a better understanding how to optimize the perioperative care of patients with narcolepsy.
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Affiliation(s)
- Shelley Hershner
- From the Department of Neurology, University of Michigan, Ann Arbor, Michigan
| | - Yves Dauvilliers
- Neurology and Physiology, Department of Neurology, Gui-de-Chauliac Hospital, Montpellier, France
| | - Frances Chung
- Department of Anesthesiology, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Mandeep Singh
- Department of Anesthesia and Pain Management, Women's College Hospital and Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.,Toronto Sleep and Pulmonary Centre, Toronto, Canada
| | - Jean Wong
- Department of Anesthesiology, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Bhargavi Gali
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota
| | - Rahul Kakkar
- Narcolepsy Network Inc, Lynnwood, WA.,Prana Health, Doral, Florida
| | - Emmanuel Mignot
- Department of Psychiatry and Behavioral Sciences, Stanford Center for Sleep Sciences and Medicine, Palo Alto, CA
| | - Michael Thorpy
- Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Dennis Auckley
- Division of Pulmonary, Critical Care and Sleep Medicine, Metro Health Medical Center, Case Western Reserve University, Cleveland, Ohio
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23
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Affiliation(s)
- Dennis Auckley
- Case Western Reserve University Cleveland, OH, United States
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24
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Affiliation(s)
- Dennis Auckley
- Division of Pulmonary, Critical Care and Sleep Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
- Society of Anesthesia and Sleep Medicine, Milwaukee, Wisconsin
| | - Stavros Memtsoudis
- Society of Anesthesia and Sleep Medicine, Milwaukee, Wisconsin
- Anesthesia and Health Policy and Research, Weill Cornell Medical College, New York, New York
- Department of Anesthesiology, Hospital for Special Surgery, New York, New York
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25
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Khalid F, Ayache M, Auckley D. 0697 Gender Bias with Centers for Medicare and Medicaid Services Scoring Criteria when Diagnosing Obstructive Sleep Apnea. Sleep 2019. [DOI: 10.1093/sleep/zsz067.695] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Faiza Khalid
- Pulmonary, critical care and sleep medicine, Case western reserve university, Beachwood, OH, USA
| | - Mirna Ayache
- Case Western Reserve University, Cleveland, OH, USA
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26
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Walia HK, Shalhoub G, Ramsammy V, Harrington M, Thornton JD, Auckley D. Symptoms of Restless Legs Syndrome in A Palliative Care Population: Frequency and Impact. J Palliat Care 2018. [DOI: 10.1177/082585971302900402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objectives: We hypothesized that restless legs syndrome (RLS) would be common and associated with impaired quality of life (QOL) among palliative care outpatients. Methods: 76 palliative care clinic patients completed the National Institutes of Health restless legs syndrome (NIH-RLS) screening questionnaire. Questionnaire data was also gathered on RLS severity and RLS-related QOL, and the Short Form Health Survey (SF-12) was used to measure QOL. Analysis was performed for associations between RLS categorization and QOL measures. Results: 31 patients (40.8 percent) met criteria for RLS. RLS-positive patients had moderate-to-severe RLS symptoms and impaired RLS-specific QOL. RLS-positive patients scored lower on the mental component of the SF–12 (39 ± 11 versus 45 ± 12, p=0.03), though not on the physical component. In a multivariate regression analysis, higher levels of RLS severity had 2-point lower SF-12 mental component scores compared to lower levels of RLS severity (p=0.04), with no difference in physical component scores (p=0.47). Conclusion: RLS appears common in palliative care outpatients and is associated with impairments in QOL.
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Affiliation(s)
- Harneet K. Walia
- D Auckley (corresponding author) Division of Pulmonary, Critical Care and Sleep Medicine, MetroHealth Medical Center, Case Western Reserve University, 2500 MetroHealth Drive, Cleveland, Ohio, USA 44109
| | - George Shalhoub
- Center for Sleep Disorders, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - Verai Ramsammy
- Division of Internal Medicine, Womack Army Medical Center, Fort Bragg, North Carolina, USA
| | - Michael Harrington
- Division of Pulmonary, Critical Care and Sleep Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - J. Daryl Thornton
- Division of Palliative Care Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Dennis Auckley
- Center for Reducing Health Disparities, Division of Pulmonary, Critical Care and Sleep Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
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27
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Shafi MI, Liaquat S, Auckley D. Up in smoke: An unusual case of diffuse alveolar hemorrhage from marijuana. Respir Med Case Rep 2018; 25:22-24. [PMID: 29998053 PMCID: PMC6038329 DOI: 10.1016/j.rmcr.2018.05.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Revised: 05/28/2018] [Accepted: 05/30/2018] [Indexed: 12/27/2022] Open
Abstract
Diffuse alveolar hemorrhage (DAH) can be a serious and life threating condition. Illicit substance use has been associated with DAH, with cocaine being the most widely reported. Marijuana use has been associated with pulmonary complications in the form of pneumomediatsium, pneumothorax, bullous disease, and pulmonary aspergillosis. We present a case of diffuse alveolar hemorrhage (DAH) resulting from marijuana inhalation, a finding rarely described in the literature. A 21-year-old male presented with several episodes of hemoptysis after drinking alcohol and smoking marijuana. He reported smoking 5–8 joints per day of marijuana (he denied use of bongs or other inhalant aids). His respiratory exam revealed bilateral fine rales. Laboratory evaluation included leukocytosis with left shift, normal platelets, coagulation profile, and a urine toxicology screen positive for tetrahydocanabinoid (THC). Chest CT revealed bilateral diffuse alveolar infiltrates suggestive of DAH. A bronchoscopy with BAL of bilateral upper lobes consistent with DAH with negative microbiologic studies, hemosiderin laden macrophages were present. Additional workup included a normal Echocardiogram, negative autoimmune serologies. His hemoptysis resolved with supportive care. DAH is a potentially fatal disease that has been associated with illicit substance use, most commonly cocaine. Recently, reports have surfaced associating marijuana use with DAH, though these cases have all involved the use of bongs or other inhalant aids, leading to the hypothesis that combustibles and inhaled particles may be the etiologic factor. This is the second report of DAH developing after smoking only marijuana, though the etiology for the association between marijuana use and DAH remains uncertain.
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Affiliation(s)
- M I Shafi
- Division of Pulmonary, Critical Care and Sleep Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - S Liaquat
- Division of Pulmonary, Critical Care and Sleep Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
| | - D Auckley
- Division of Pulmonary, Critical Care and Sleep Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH, USA
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28
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Baba RY, Soma D, Sediqe S, Kondapaneni M, Auckley D. 0596 Impact of Obstructive Sleep Apnea on Clinical Outcomes in Acute Coronary Syndrome. Sleep 2018. [DOI: 10.1093/sleep/zsy061.595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- R Y Baba
- MetroHealth Medical Center, Cleveland, OH
| | - D Soma
- MetroHealth Medical Center, Cleveland, OH
| | - S Sediqe
- MetroHealth Medical Center, Cleveland, OH
| | | | - D Auckley
- MetroHealth Medical Center, Cleveland, OH
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29
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Carter JC, Auckley D. Watch What You're Doing! J Clin Sleep Med 2018; 14:301-302. [PMID: 29458708 DOI: 10.5664/jcsm.6962] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 01/25/2018] [Indexed: 11/13/2022]
Affiliation(s)
- John C Carter
- Department of Pediatrics and Division of Pulmonary, Critical Care and Sleep Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Dennis Auckley
- Division of Pulmonary, Critical Care and Sleep Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
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30
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Abstract
Noninvasively applied positive airway pressure therapy (PAP) is available in 3 basic modes: continuous positive airway pressure (CPAP), bi-level positive airway pressure (BPAP), and adaptive servo-ventilation. These are in widespread use in home and hospital settings to treat a variety of disorders of ventilation or gas exchange, including obstructive sleep apnea, sleep-related hypoventilation, periodic breathing, acute and chronic hypercapnic respiratory failure, and acute respiratory failure. They are increasingly being used perioperatively to prevent or treat upper airway obstruction, hypoventilation, and periodic breathing, and they have been found to improve postoperative outcomes in the case of obstructive sleep apnea. An impediment to their use in this setting is a lack of familiarity with their application by hospital clinical staff. This review describes the modes of PAP therapy available, their indications, how therapy is initiated, how efficacy is assessed, common problems encountered with its use, and how these problems can be addressed.
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Affiliation(s)
- David R Hillman
- Centre for Sleep Science, University of Western Australia, Department of Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital, Perth, Australia
| | | | - Dennis Auckley
- Division of Pulmonary, Critical Care and Sleep Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, OH
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31
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Gandotra K, May A, Auckley D. Variable Response to CPAP in a Case of Severe Obstructive Sleep Apnea: An Unusual Cause. J Clin Sleep Med 2018; 14:145-148. [PMID: 29198296 DOI: 10.5664/jcsm.6904] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [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: 08/19/2017] [Accepted: 09/26/2017] [Indexed: 11/13/2022]
Abstract
ABSTRACT The objective of this report is to present clinical and scientific evidence to support the role of head position in the management of obstructive sleep apnea (OSA) with positive airway pressure. OSA, characterized by repetitive obstruction of the upper is a common medical condition associated with daytime somnolence, morning headaches, mood disturbances, and a variety of cardiopulmonary complications. The role of head position during obstructive respiratory events has been largely overlooked. We present a case where OSA severity decreased significantly with the head rotated in the right lateral position compared to head position in the neutral and left position. This case demonstrates an important influence of head position during continuous positive airway pressure titration, independent of trunk position and sleep stage, in patients with OSA, and highlights the utility of the video polysomnography for identifying the variant.
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Affiliation(s)
- Kamal Gandotra
- Division of Pulmonary Critical Care and Sleep Medicine, Louis Stokes VA Medical Center, Cleveland, Ohio
| | - Anna May
- Division of Pulmonary, Critical Care and Sleep Medicine, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Dennis Auckley
- Division of Pulmonary, Critical Care and Sleep Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio
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Hu S, Singh M, Wong J, Auckley D, Hershner S, Kakkar R, Thorpy MJ, Chung F. Anesthetic Management of Narcolepsy Patients During Surgery: A Systematic Review. Anesth Analg 2018; 126:233-246. [PMID: 29257771 DOI: 10.1213/ane.0000000000002228] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Narcolepsy is a rare sleep disorder characterized by excessive daytime sleepiness, sleep paralysis, and/or hypnagogic/hypnopompic hallucinations, and in some cases cataplexy. The response to anesthetic medications and possible interactions in narcolepsy patients is unclear in the perioperative period. In this systematic review, we aim to evaluate the current evidence on the perioperative outcomes and anesthetic considerations in narcolepsy patients. METHODS Electronic literature search of Medline, Medline in-process, Embase, Cochrane Database of Systematic Reviews databases, international conference proceedings, and abstracts was conducted in November 2015 according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols guideline. A total of 3757 articles were screened using a 2-stage strategy (title-abstract followed by full text). We included case studies/series, cohort studies, and randomized controlled trials of narcolepsy patients undergoing surgical procedures under anesthesia or sedation. Preoperative narcolepsy symptoms and sleep study data, anesthetic technique, and perioperative complications were extracted. Screening of articles, data extraction, and compilation were conducted by 2 independent reviewers and any conflict was resolved by the senior author. RESULTS A total of 19 studies including 16 case reports and 3 case series were included and evaluated. The majority of these patients received general anesthesia, whereas a small percentage of patients received regional anesthesia. Reported complications of narcolepsy patients undergoing surgeries were mainly related to autonomic dysregulation, or worsening of narcolepsy symptoms intra/postoperatively. Narcolepsy symptoms worsened only in those patient populations where the preoperative medications were either discontinued or reduced (mainly in obstetric patients). In narcolepsy patients, use of depth of anesthesia monitoring and total intravenous technique may have some advantage in terms of safety profile. Several patients undergoing neurosurgery involving the hypothalamus or third or four ventricles developed new-onset narcolepsy. CONCLUSIONS We found a paucity of prospective clinical trials in this patient population, as most of the studies were case reports or observational studies. Continuation of preoperative medications, depth of anesthesia monitoring, use of multimodal analgesia with short-acting agents and regional anesthesia techniques were associated with favorable outcomes. Obstetric patients may be at greater risk for worsening narcolepsy symptoms, possibly related to a reduction or discontinuation of medications. For neurosurgical procedures involving the hypothalamus or third and fourth ventricle, postoperative considerations should include monitoring for symptoms of narcolepsy. Future studies are needed to better define perioperative risks associated with anesthesia and surgery in this population of patients.
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Affiliation(s)
- Sally Hu
- From the Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Mandeep Singh
- Department of Anesthesiology, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada.,Toronto Sleep and Pulmonary Centre, Toronto, Canada.,Department of Anesthesiology, Women's College Hospital, Toronto, Ontario, Canada
| | - Jean Wong
- Department of Anesthesiology, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Dennis Auckley
- Division of Pulmonary, Critical Care and Sleep Medicine, Metro Health Medical Centre, Case Western Reserve University, Cleveland, Ohio
| | - Shelley Hershner
- Department of Neurology, University of Michigan, Ann Arbor, Michigan
| | - Rahul Kakkar
- Pulmonary Medicine, Sleep Medicine, Prana Health, Apex, North Carolina
| | - Michael J Thorpy
- Saul R. Korey Department of Neurology, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York
| | - Frances Chung
- Department of Anesthesiology, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
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Cozma R, Margarson M, Auckley D. Sleep disordered breathing and the anaesthetist. Rom J Anaesth Intensive Care 2017; 23:101-102. [PMID: 28913482 DOI: 10.21454/rjaic.7518/232.sld] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
| | | | - Dennis Auckley
- MetroHealth Medical Center, Cleveland, Ohio USA, Society for Anaesthesia and Sleep Medicine (www.sasm.org)
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Chung F, Memtsoudis SG, Ramachandran SK, Nagappa M, Opperer M, Cozowicz C, Patrawala S, Lam D, Kumar A, Joshi GP, Fleetham J, Ayas N, Collop N, Doufas AG, Eikermann M, Englesakis M, Gali B, Gay P, Hernandez AV, Kaw R, Kezirian EJ, Malhotra A, Mokhlesi B, Parthasarathy S, Stierer T, Wappler F, Hillman DR, Auckley D. Society of Anesthesia and Sleep Medicine Guidelines on Preoperative Screening and Assessment of Adult Patients With Obstructive Sleep Apnea. Anesth Analg 2017; 123:452-73. [PMID: 27442772 PMCID: PMC4956681 DOI: 10.1213/ane.0000000000001416] [Citation(s) in RCA: 200] [Impact Index Per Article: 28.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Supplemental Digital Content is available in the text. The purpose of the Society of Anesthesia and Sleep Medicine guideline on preoperative screening and assessment of adult patients with obstructive sleep apnea (OSA) is to present recommendations based on the available clinical evidence on the topic where possible. As very few well-performed randomized studies in this field of perioperative care are available, most of the recommendations were developed by experts in the field through consensus processes involving utilization of evidence grading to indicate the level of evidence upon which recommendations were based. This guideline may not be appropriate for all clinical situations and all patients. The decision whether to follow these recommendations must be made by a responsible physician on an individual basis. Protocols should be developed by individual institutions taking into account the patients’ conditions, extent of interventions and available resources. This practice guideline is not intended to define standards of care or represent absolute requirements for patient care. The adherence to these guidelines cannot in any way guarantee successful outcomes and is rather meant to help individuals and institutions formulate plans to better deal with the challenges posed by perioperative patients with OSA. These recommendations reflect the current state of knowledge and its interpretation by a group of experts in the field at the time of publication. While these guidelines will be periodically updated, new information that becomes available between updates should be taken into account. Deviations in practice from guidelines may be justifiable and such deviations should not be interpreted as a basis for claims of negligence.
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Affiliation(s)
- Frances Chung
- From the *Department of Anesthesiology, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada; †Department of Anesthesiology, Weill Cornell Medical College and Hospital for Special Surgery, New York, New York; ‡Department of Anesthesiology, University of Michigan, Ann Arbor, Michigan; §Department of Anesthesiology and Perioperative Medicine, University Hospital, St. Joseph's Hospital and Victoria Hospital, London Health Sciences Centre and St. Joseph's Health care, Western University, London, Ontario, Canada; ‖Paracelsus Medical University, Department of Anesthesiology, Perioperative Medicine and Intensive Care, Salzburg, Austria; ¶Department of Anesthesiology, Hospital for Special Surgery, Weill Cornell Medical College New York, New York; #Department of Anesthesia, Perioperative Medicine and Intensive Care, Paracelsus Medical University, Salzburg, Austria; **Department of Medicine, University of California San Diego, San Diego, California; ††Sparrow Hospital, Lansing, Michigan; ‡‡Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical School, Texas; §§Department of Medicine, Division of Respiratory Medicine, The University of British Columbia, Vancouver, BC, Canada; ‖‖University of British Columbia, Vancouver, BC, Canada; ¶¶Department of Medicine, Emory University, Atlanta, Georgia; ##Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University Medical Center, Palo Alto, California; ***Department of Anesthesia, Critical Care and Pain Medicine, Harvard University, Cambridge, Massachusetts; †††Library and Information Services, University Health Network, University of Toronto, Toronto, Ontario, Canada; ‡‡‡Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota; §§§Department of Pulmonary, Critical Care and Sleep Medicine, Mayo Clinic, Rochester, Minnesota; ‖‖‖School of Medicine, Universidad Peruana de Ciencias Apl
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DeMartino T, Ghoul RE, Wang L, Bena J, Hazen SL, Tracy R, Patel SR, Auckley D, Mehra R. Oxidative Stress and Inflammation Differentially Elevated in Objective Versus Habitual Subjective Reduced Sleep Duration in Obstructive Sleep Apnea. Sleep 2016; 39:1361-9. [PMID: 27091532 DOI: 10.5665/sleep.5964] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [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: 11/10/2015] [Accepted: 03/19/2016] [Indexed: 11/03/2022] Open
Abstract
STUDY OBJECTIVES Data have demonstrated adverse health effects of sleep deprivation. We postulate that oxidative stress and systemic inflammation biomarkers will be elevated in relation to short-term and long-term sleep duration reduction. METHODS We analyzed data from the baseline examination of a randomized controlled trial involving participants with moderate to severe obstructive sleep apnea (OSA). Baseline polysomnography provided the total sleep time (PSG-TST, primary predictor); self-reported habitual sleep duration (SR-HSD) data was collected. Morning measures of oxidative stress and systemic inflammation included: myeloperoxidase (MPO, pmol/L), oxidized low-density lipoprotein (ox-LDL, U/L), F2-isoprostane (ng/mg), paraoxonase 1 (PON1, nmol·min(-1)·mL(-1)), and aryl esterase (μmol·min(-1)·mL(-1)). Linear models adjusted for age, sex, race, body mass index (BMI), cardiovascular disease (CVD), smoking, statin/anti-inflammatory medications, and apnea-hypopnea index were utilized (beta estimates and 95% confidence intervals). RESULTS One hundred forty-seven participants comprised the final analytic sample; they were overall middle-aged (51.0 ± 11.7 y), obese (BMI = 37.3 ± 8.1 kg/m(2)), and 17% had CVD. Multivariable models demonstrated a significant inverse association of PSG-TST and MPO (β [95% CI] = -20.28 [-37.48, -3.08], P = 0.021), i.e., 20.3 pmol/L MPO reduction per hour increase PSG-TST. Alternatively, a significant inverse association with ox-LDL and SR-HSD was observed (β [95% CI] = 0.98 [0.96, 0.99], P = 0.027), i.e., 2% ox-LDL reduction per hour increase SR-HSD. CONCLUSIONS Even after consideration of obesity and OSA severity, inverse significant findings were observed such that reduced PSG-TST was associated with elevated MPO levels and SR-HSD with ox-LDL, suggesting differential up-regulation of oxidative stress and pathways of inflammation in acute versus chronic sleep curtailment. CLINICAL TRIAL REGISTRATION NIH clinical trials registry number NCT00607893.
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Affiliation(s)
| | - Rawad El Ghoul
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University Hospitals Case Medical Center, Cleveland, OH
| | - Lu Wang
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - James Bena
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Stanley L Hazen
- Department of Molecular Cardiology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Russel Tracy
- Departments of Biochemistry and Pathology, University of Vermont, Burlington, VT
| | - Sanjay R Patel
- Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Dennis Auckley
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, MetroHealth Medical Center, Cleveland, OH
| | - Reena Mehra
- Department of Molecular Cardiology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH.,Sleep Center, Neurologic Institute, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH
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Opperer M, Cozowicz C, Bugada D, Mokhlesi B, Kaw R, Auckley D, Chung F, Memtsoudis SG. Does Obstructive Sleep Apnea Influence Perioperative Outcome? A Qualitative Systematic Review for the Society of Anesthesia and Sleep Medicine Task Force on Preoperative Preparation of Patients with Sleep-Disordered Breathing. Anesth Analg 2016; 122:1321-34. [DOI: 10.1213/ane.0000000000001178] [Citation(s) in RCA: 143] [Impact Index Per Article: 17.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
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Paz Y Mar HL, Hazen SL, Tracy RP, Strohl KP, Auckley D, Bena J, Wang L, Walia HK, Patel SR, Mehra R. Effect of Continuous Positive Airway Pressure on Cardiovascular Biomarkers: The Sleep Apnea Stress Randomized Controlled Trial. Chest 2016; 150:80-90. [PMID: 26997243 DOI: 10.1016/j.chest.2016.03.002] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.9] [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: 11/13/2015] [Revised: 02/26/2016] [Accepted: 03/01/2016] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Although existing research highlights the relationship of OSA and cardiovascular disease, the effect of OSA treatment on cardiovascular biomarkers remains unclear. We evaluated the effect of OSA treatment on oxidative stress/inflammation measures. METHODS We conducted a parallel, randomized controlled trial in moderate to severe OSA (apnea-hypopnea index ≥ 15) patients to examine effects of 2-month CPAP vs sham-CPAP on the primary outcome of oxidative stress/inflammation (F2-isoprostanes: ng/mg) and myeloperoxidase: pmol/L) and secondary oxidative stress measures. Exploratory secondary analyses included vascular and systemic inflammation markers. Linear models adjusted for baseline values examined effect of CPAP on biomarker change (least squares means, 95% CI) including secondary stratified analyses examining CPAP adherence and degree of hypoxia. RESULTS Of 153 participants, 76 were randomized to CPAP and 77 to sham-CPAP. In an intent-to-treat analyses, no significant change was observed in the sham and CPAP groups respectively: F2-isoprostanes (-0.02 [-0.12 to 0.10] vs -0.08 [-0.18 to 0.03]) or myeloperoxidase (-3.33 [-17.02 to 10.37] vs -5.15 [-18.65 to 8.35]), nor other oxidative markers; findings that persisted in analyses stratified by adherence and hypoxia. Exploratory analyses revealed percentage reduction of soluble IL-6 receptor (ng/mL) levels (-0.04 [-0.08 to -0.01] vs 0.02 [-0.02 to 0.06], P = .019) and augmentation index (%) (-6.49 [-9.32 to -3.65] vs 0.44 [-2.22 to 3.10], P < .001) with CPAP compared with sham, respectively. CONCLUSIONS In moderate to severe OSA, 2-month CPAP vs sham did not reduce oxidative stress despite consideration of a broad range of measures, positive airway pressure adherence, and hypoxia burden. These findings suggest that nonoxidative stress pathways primarily modulate OSA-related cardiovascular consequences. TRIAL REGISTRATION ClinicalTrials.govNCT00607893.
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Affiliation(s)
- Hugo L Paz Y Mar
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Stanley L Hazen
- Department of Cellular and Molecular Medicine, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Russell P Tracy
- Departments of Biochemistry and Pathology, University of Vermont, Burlington, VT
| | - Kingman P Strohl
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, University Hospitals Case Medical Center, Case Western Reserve University, Cleveland, OH
| | - Dennis Auckley
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, MetroHealth Medical Center, Cleveland, OH
| | - James Bena
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Lu Wang
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, OH
| | - Harneet K Walia
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Sanjay R Patel
- Division of Sleep and Circadian Disorders, Brigham and Women's Hospital and Division of Pulmonary, Critical Care and Sleep Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Reena Mehra
- Sleep Disorders Center, Neurological Institute, Cleveland Clinic, Cleveland, OH; Department of Molecular Cardiology, Lerner Research Institute, Cleveland Clinic, Cleveland, OH.
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Nagappa M, Liao P, Wong J, Auckley D, Ramachandran SK, Memtsoudis S, Mokhlesi B, Chung F. Validation of the STOP-Bang Questionnaire as a Screening Tool for Obstructive Sleep Apnea among Different Populations: A Systematic Review and Meta-Analysis. PLoS One 2015; 10:e0143697. [PMID: 26658438 PMCID: PMC4678295 DOI: 10.1371/journal.pone.0143697] [Citation(s) in RCA: 349] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 11/09/2015] [Indexed: 11/18/2022] Open
Abstract
Background Diagnosing obstructive sleep apnea (OSA) is clinically relevant because untreated OSA has been associated with increased morbidity and mortality. The STOP-Bang questionnaire is a validated screening tool for OSA. We conducted a systematic review and meta-analysis to determine the effectiveness of STOP-Bang for screening patients suspected of having OSA and to predict its accuracy in determining the severity of OSA in the different populations. Methods A search of the literature databases was performed. Inclusion criteria were: 1) Studies that used STOP-Bang questionnaire as a screening tool for OSA in adult subjects (>18 years); 2) The accuracy of the STOP-Bang questionnaire was validated by polysomnography—the gold standard for diagnosing OSA; 3) OSA was clearly defined as apnea/hypopnea index (AHI) or respiratory disturbance index (RDI) ≥ 5; 4) Publications in the English language. The quality of the studies were explicitly described and coded according to the Cochrane Methods group on the screening and diagnostic tests. Results Seventeen studies including 9,206 patients met criteria for the systematic review. In the sleep clinic population, the sensitivity was 90%, 94% and 96% to detect any OSA (AHI ≥ 5), moderate-to-severe OSA (AHI ≥15), and severe OSA (AHI ≥30) respectively. The corresponding NPV was 46%, 75% and 90%. A similar trend was found in the surgical population. In the sleep clinic population, the probability of severe OSA with a STOP-Bang score of 3 was 25%. With a stepwise increase of the STOP-Bang score to 4, 5, 6 and 7/8, the probability rose proportionally to 35%, 45%, 55% and 75%, respectively. In the surgical population, the probability of severe OSA with a STOP-Bang score of 3 was 15%. With a stepwise increase of the STOP-Bang score to 4, 5, 6 and 7/8, the probability increased to 25%, 35%, 45% and 65%, respectively. Conclusion This meta-analysis confirms the high performance of the STOP-Bang questionnaire in the sleep clinic and surgical population for screening of OSA. The higher the STOP-Bang score, the greater is the probability of moderate-to-severe OSA.
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Affiliation(s)
- Mahesh Nagappa
- Department of Anesthesiology, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Pu Liao
- Department of Anesthesiology, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Jean Wong
- Department of Anesthesiology, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | - Dennis Auckley
- Division of Pulmonary, Critical Care and Sleep Medicine, Metro Health Medical Center, Case Western Reserve University, Cleveland, OH, United States of America
| | - Satya Krishna Ramachandran
- Department of Anesthesiology, University of Michigan Health System, East Medical Center Drive, Michigan, United States of America
| | - Stavros Memtsoudis
- Department of Anesthesiology, Hospital for Special Surgery, Weill Medical College of Cornell University, New York, United States of America
| | - Babak Mokhlesi
- Department of Medicine, Sleep Disorders Center and the Section of Pulmonary and Critical Care, University of Chicago, Chicago, Illinois, United States of America
| | - Frances Chung
- Department of Anesthesiology, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
- * E-mail:
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Auckley D. Sleep apnea – another piece of the postoperative delirium puzzle? Crit Care 2014. [DOI: 10.1186/s13054-014-0667-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Billings ME, Rosen CL, Auckley D, Benca R, Foldvary-Schaefer N, Iber C, Zee PC, Redline S, Kapur VK. Psychometric performance and responsiveness of the functional outcomes of sleep questionnaire and sleep apnea quality of life instrument in a randomized trial: the HomePAP study. Sleep 2014; 37:2017-24. [PMID: 25325491 DOI: 10.5665/sleep.4262] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [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: 08/22/2013] [Accepted: 07/08/2014] [Indexed: 11/03/2022] Open
Abstract
STUDY OBJECTIVES Measures of health-related quality of life (HRQL) specific for sleep disorders have had limited psychometric evaluation in the context of randomized controlled trials (RCTs). We investigated the psychometric properties of the Functional Outcomes of Sleep Questionnaire (FOSQ) and Sleep Apnea Quality of Life Instrument (SAQLI). We evaluated the FOSQ and SAQLI construct and criterion validity, determined a minimally important difference, and assessed for associations of responsiveness to baseline subject characteristics and continuous positive airway pressure (CPAP) adherence in a RCT population. DESIGN Secondary analysis of data collected in a multisite RCT of home versus laboratory-based diagnosis and treatment of obstructive sleep apnea (HomePAP trial). PARTICIPANTS Individuals enrolled in the HomePAP trial (n = 335). INTERVENTIONS N/A. MEASUREMENT AND RESULTS The FOSQ and SAQLI subscores demonstrated high reliability and criterion validity, correlating with Medical Outcomes Study 36-Item Short Form Survey domains. Correlations were weaker with the Epworth Sleepiness Scale (ESS). Both the FOSQ and SAQLI scores improved after 3 mo with CPAP therapy. Averaging 4 h or more of CPAP use was associated with an increase in the FOSQ beyond the minimally important difference. Baseline depressive symptoms and sleepiness predicted FOSQ and SAQLI responsiveness; demographic, objective obstructive sleep apnea (OSA) severity and sleep habits were not predictive in linear regression. CONCLUSIONS The FOSQ and SAQLI are responsive to CPAP intervention, with the FOSQ being more sensitive to differences in CPAP adherence than the SAQLI. These instruments provide unique information about health outcomes beyond that provided by changes in physiological measures of OSA severity (apnea-hypopnea index). CLINICAL TRIAL INFORMATION Portable Monitoring for Diagnosis and Management of Sleep Apnea (HomePAP) URL: http://clinicaltrials.gov/show/NCT00642486. NIH clinical trials registry number: NCT00642486.
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Affiliation(s)
- Martha E Billings
- UW Medicine Sleep Center, Division of Pulmonary Critical Care, University of Washington, Seattle, WA
| | - Carol L Rosen
- Case Western Reserve University, School of Medicine, Cleveland, OH: Rainbow Babies and Children's Hospital, University Hospitals, Case Medical Center, Cleveland, OH
| | - Dennis Auckley
- Case Western Reserve University, School of Medicine, Cleveland, OH: Center for Sleep Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, MetroHealth Medical Center, Cleveland, OH
| | - Ruth Benca
- Department of Psychiatry, University of Wisconsin, Madison, WI
| | - Nancy Foldvary-Schaefer
- Case Western Reserve University, School of Medicine, Cleveland, OH: Cleveland Clinic, Cleveland, OH
| | - Conrad Iber
- Hennepin County Medical Center, University of Minnesota, Minneapolis, MN
| | - Phyllis C Zee
- Northwestern University, Feinberg School of Medicine, Chicago, IL
| | - Susan Redline
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA
| | - Vishesh K Kapur
- UW Medicine Sleep Center, Division of Pulmonary Critical Care, University of Washington, Seattle, WA
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Auckley D. Another shout out for OSA! The association between voice performance, OSA, and CPAP therapy. Commentary on: The effect of OSAS and CPAP on voice performance by Antan D, Ozcan KM, Ikinciogullari A, et al. Sleep Breath 2014; 19:783-4. [PMID: 25758297 DOI: 10.1007/s11325-014-1079-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2014] [Accepted: 11/10/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Dennis Auckley
- Division of Pulmonary, Critical Care and Sleep Medicine, MetroHealth Medical Center, Case Western Reserve University, BG 3-90, 2500 MetroHealth Dr, Cleveland, OH, 44109, USA,
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Grewal M, Khosa S, Auckley D. Sleep Quality in Patients Admitted to the General Medical Floors. Chest 2014. [DOI: 10.1378/chest.1993670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Auckley D, Cox R, Bolden N, Thornton JD. Attitudes regarding perioperative care of patients with OSA: a survey study of four specialties in the United States. Sleep Breath 2014; 19:315-25. [DOI: 10.1007/s11325-014-1023-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Revised: 05/14/2014] [Accepted: 06/13/2014] [Indexed: 10/25/2022]
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Billings ME, Rosen CL, Wang R, Auckley D, Benca R, Foldvary-Schaefer N, Iber C, Zee P, Redline S, Kapur VK. Is the relationship between race and continuous positive airway pressure adherence mediated by sleep duration? Sleep 2013; 36:221-7. [PMID: 23372269 DOI: 10.5665/sleep.2376] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
STUDY OBJECTIVES Black race has been associated with decreased continuous positive airway pressure (CPAP) adherence. Short sleep duration, long sleep latency, and insomnia complaints may affect CPAP adherence as they affect sleep and opportunity to use CPAP. We assessed whether self-reported sleep measures were associated with CPAP adherence and if racial variations in these sleep characteristics may explain racial differences in CPAP adherence. DESIGN Analysis of data from a randomized controlled trial (HomePAP), which investigated home versus laboratory-based diagnosis and treatment of obstructive sleep apnea. SETTING Seven American Academy of Sleep Medicine-accredited sleep centers in five cities in the United States. PATIENTS OR PARTICIPANTS Enrolled subjects (n = 191) with apnea-hypopnea index ≥ 15 and sleepiness (Epworth Sleepiness Scale > 12). INTERVENTIONS N/A. MEASUREMENTS AND RESULTS Multivariable regression was used to assess if subjective sleep measures and symptoms predicted 3-mo CPAP use. Mediation analysis was used to assess if sleep measures mediated the association of race with CPAP adherence. Black participants reported shorter sleep duration and longer sleep latency at baseline than white and Hispanic participants. Shorter sleep duration and longer sleep latency predicted worse CPAP adherence. Sleep duration mediated the association of black race with lower CPAP adherence. However, insomnia symptoms were not associated with race or CPAP adherence. CONCLUSIONS Among subjects with similar severity of obstructive sleep apnea and sleepiness, baseline self-reported sleep duration and latency, but not perceived insomnia, predicted CPAP adherence over 3 mo. Sleep duration explains some of the observed differences in CPAP use by race. Sleep duration and latency should be considered when evaluating poor CPAP adherence. CLINICAL TRIAL INFORMATION PORTABLE MONITORING FOR DIAGNOSIS AND MANAGEMENT OF SLEEP APNEA (HOMEPAP) URL: http://clinicaltrials.gov/show/NCT00642486. NIH clinical trials registry number: NCT00642486.
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Affiliation(s)
- Martha E Billings
- UW Medicine Sleep Center, Division of Pulmonary Critical Care, University of Washington, Seattle, WA 98104, USA.
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Vricella L, Auckley D, Louis J. 38: Obstructive sleep apnea and cardiovascular disease in pregnant and non-pregnant women. Am J Obstet Gynecol 2013. [DOI: 10.1016/j.ajog.2012.10.212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Walia HK, Shalhoub G, Ramsammy V, Harrington M, Thornton JD, Auckley D. Symptoms of restless legs syndrome in a palliative care population: frequency and impact. J Palliat Care 2013; 29:210-216. [PMID: 24601071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
OBJECTIVES We hypothesized that restless legs syndrome (RLS) would be common and associated with impaired quality of life (QOL) among palliative care outpatients. METHODS 76 palliative care clinic patients completed the National Institutes of Health restless legs syndrome (NIH-RLS) screening questionnaire. Questionnaire data was also gathered on RLS severity and RLS-related QOL, and the Short Form Health Survey (SF-12) was used to measure QOL. Analysis was performed for associations between RLS categorization and QOL measures. RESULTS 31 patients (40.8 percent) met criteria for RLS. RLS-positive patients had moderate-to-severe RLS symptoms and impaired RLS-specific QOL. RLS-positive patients scored lower on the mental component of the SF-12 (39 +/- 11 versus 45 +/- 12, p=0.03), though not on the physical component. In a multivariate regression analysis, higher levels of RLS severity had 2-point lower SF-12 mental component scores compared to lower levels of RLS severity (p=0.04), with no difference in physical component scores (p=0.47). CONCLUSION RLS appears common in palliative care outpatients and is associated with impairments in QOL.
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Affiliation(s)
- Harneet K Walia
- Center for Sleep Disorders, Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | - George Shalhoub
- Division of Internal Medicine, Womack Army Medical Center, Fort Bragg, North Carolina, USA
| | - Verai Ramsammy
- Division of Pulmonary, Critical Care and Sleep Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Michael Harrington
- Division of Palliative Care Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - J Daryl Thornton
- Center for Reducing Health Disparities, Division of Pulmonary, Critical Care and Sleep Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Dennis Auckley
- Division of Pulmonary, Critical Care and Sleep Medicine, MetroHealth Medical Center, Case Western Reserve University, Cleveland, Ohio, USA 44109
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Louis J, Auckley D, Miladinovic B, Shepherd A, Mencin P, Kumar D, Mercer B, Redline S. Perinatal outcomes associated with obstructive sleep apnea in obese pregnant women. Obstet Gynecol 2012; 120:1085-92. [PMID: 23090526 PMCID: PMC3552141 DOI: 10.1097/aog.0b013e31826eb9d8] [Citation(s) in RCA: 151] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVE To investigate the associations between obstructive sleep apnea (OSA) and maternal and neonatal morbidities in a cohort of obese gravid women. METHODS Participants were enrolled in a prospective observational study designed to screen for OSA and describe the possible risk factors for and outcomes of OSA among obese (body mass index [BMI, calculated as weight (kg)/[height (m)]2] 30 or higher) pregnant women. Women underwent an overnight sleep study using a portable home monitor. Studies were manually scored by a central masked sleep reading center using American Academy of Sleep Medicine diagnostic criteria. An apnea hypopnea index of 5 or more was considered diagnostic of OSA. Perinatal outcomes were compared between women with and without OSA. RESULTS Among 175 women, OSA prevalence was 15.4% (13 mild, 9 moderate, 5 severe). Compared with no OSA (apnea hypopnea index less than 5), the OSA group had a higher BMI (46.8±12.2 compared with 38.1±7.5; P=.002) and more chronic hypertension (55.6% compared with 32.4%, P=.02). Maternal complications included maternal death (n=1, amniotic fluid embolus [no OSA group]) and cardiac arrest (n=1, intraoperative at cesarean delivery [OSA group]). One previable birth and two stillbirths occurred in the no OSA group. Among live births, OSA was associated with more frequent cesarean delivery (65.4% compared with 32.8%; P=.003), preeclampsia (42.3% compared with 16.9%; P=.005), and neonatal intensive care unit admission (46.1% compared with 17.8%; P=.002). After controlling for BMI, maternal age, and diabetes, OSA (odds ratio [OR] 3.55, 95% confidence interval [CI] 1.1-11.3), previous preeclampsia (OR 2.79, 95% CI 1.09-7.19), and hypertension (OR 4.25, 95% CI 1.67-10.77) were associated with development of preeclampsia. CONCLUSION Obstructive sleep apnea among obese pregnant women is associated with more frequent preeclampsia, neonatal intensive care unit admissions, and cesarean delivery. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Judette Louis
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, MetroHealth Medical Center-Case Western Reserve University School of Medicine, Cleveland, Ohio 44109, USA.
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Salem B, Newman C, Auckley D. The Prevalence of Sleep Disordered Breathing in Hospitalized Medical Patients. Chest 2012. [DOI: 10.1378/chest.1387001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Rosen CL, Auckley D, Benca R, Foldvary-Schaefer N, Iber C, Kapur V, Rueschman M, Zee P, Redline S. A multisite randomized trial of portable sleep studies and positive airway pressure autotitration versus laboratory-based polysomnography for the diagnosis and treatment of obstructive sleep apnea: the HomePAP study. Sleep 2012; 35:757-67. [PMID: 22654195 DOI: 10.5665/sleep.1870] [Citation(s) in RCA: 238] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
STUDY OBJECTIVES To test the utility of an integrated clinical pathway for obstructive sleep apnea (OSA) diagnosis and continuous positive airway pressure (CPAP) treatment using portable monitoring devices. DESIGN Randomized, open-label, parallel group, unblinded, multicenter clinical trial comparing home-based, unattended portable monitoring for diagnosis and autotitrating CPAP (autoPAP) compared with in-laboratory polysomnography (PSG) and CPAP titration. SETTING Seven American Academy of Sleep Medicine (AASM) accredited sleep centers. PARTICIPANTS Consecutive new referrals, age 18 yr or older with high probability of moderate to severe OSA (apnea-hypopnea index [AHI] ≥ 15) identified by clinical algorithm and Epworth Sleepiness Scale (ESS) score ≥ 12. INTERVENTIONS Home-based level 3 testing followed by 1 wk of autoPAP with a fixed pressure CPAP prescription based on the 90% pressure from autotitration of PAP therapy (autoPAP) device (HOME) compared with attended, in-laboratory studies (LAB). MEASUREMENTS CPAP acceptance, time to treatment, adherence at 1 and 3 mo; changes in ESS, and functional outcomes. RESULTS Of 373 participants, approximately one-half in each study arm remained eligible (AHI ≥ 15) to continue in the study. At 3 mo, PAP usage (nightly time at pressure) was 1 hr greater: 4.7 ± 2.1 hr (HOME) compared with 3.7 ± 2.4 hr (LAB). Adherence (percentage of night used ≥ 4 hr) was 12.6% higher: 62.8 ± 29.2% compared with 49.4 ± 36.1% in the HOME versus LAB. Acceptance of PAP therapy, titration pressures, effective titrations, time to treatment, and ESS score change did not differ between arms. CONCLUSIONS A home-based strategy for diagnosis and treatment compared with in-laboratory PSG was not inferior in terms of acceptance, adherence, time to treatment, and functional improvements. TRIAL REGISTRATION http://www.ClinicalTrials.gov; Identifier: NCT: 00642486.
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Affiliation(s)
- Carol L Rosen
- University Hospitals-Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH, USA.
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Billings ME, Auckley D, Benca R, Foldvary-Schaefer N, Iber C, Redline S, Rosen CL, Zee P, Kapur VK. Race and residential socioeconomics as predictors of CPAP adherence. Sleep 2011; 34:1653-8. [PMID: 22131602 DOI: 10.5665/sleep.1428] [Citation(s) in RCA: 123] [Impact Index Per Article: 9.5] [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: 11/03/2022] Open
Abstract
STUDY OBJECTIVES There are few established predictors of CPAP adherence; poor adherence limits its effectiveness. We investigated whether race, education level, and residential economic status predict CPAP adherence in participants enrolled in a trial with standard access to treatment. DESIGN A multi-center randomized trial of home vs. lab-based evaluation and treatment of OSA assessing adherence to CPAP at 1 and 3 months. SETTING Seven AASM-accredited sleep centers in 5 U.S. cities. PARTICIPANTS Subjects with moderate to severe OSA (AHI ≥ 15 and Epworth Sleepiness Scale score > 12) who completed follow-up at 1 and/or 3 months (n = 135). MEASUREMENTS AND RESULTS Subjects' demographic data were collected upon enrollment; CPAP use at 1 and 3 months was assessed at clinic follow-up. In unadjusted analyses, CPAP adherence (average minutes per night of CPAP use) at 3 months was lower in black subjects and in subjects from lower socioeconomic status ZIP codes. In adjusted analyses using multivariate linear regression, black race was predictive of CPAP adherence at one month (P = 0.03). At 3 months, black race was predictive in analyses only when ZIP code SES was not adjusted for. CONCLUSION Black race and lower socioeconomic residential areas are associated with poorer adherence to CPAP in subjects with standardized access to care and treatment. Disparities remain despite provision of standardized care in a clinical trial setting. Future research is needed to identify barriers to adherence and to develop interventions tailored to improve CPAP adherence in at risk populations. Portable Monitoring for Diagnosis and Management of Sleep Apnea (HomePAP) CLINICAL TRIAL INFORMATION: NIH CLINICAL TRIALS REGISTRY NUMBER: NCT00642486. URL: http://clinicaltrials.gov/show/NCT00642486.
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Affiliation(s)
- Martha E Billings
- Health Services Research & Development, Department of Veterans Affairs, Puget Sound Health Care System, 1100 Olive Way, Suite 1400, Seattle, WA 98101, USA.
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