Nocturnal Pain Crises in an Adult with Sickle Cell Disease

Sickle cell disease is the most common genetic hemoglobinopathy worldwide, characterized by a single-nucleotide mutation that predisposes to hemoglobin polymerization and erythrocyte sickling in hypoxic states. This report describes a 62-year-old male obese patient with a history of sickle cell disease, who presented with worsening nocturnal pain crises without any apparent triggering factor. A thorough evaluation at the outpatient department revealed obstructive sleep apnea. Airway obstruction or decreased respiratory effort during sleep may induce hypoventilation and hypoxia in the context of sleep-disordered breathing, with severe cardiopulmonary complications. Sleep-disordered breathing is considered common in children with sickle cell disease, but the prevalence in adults has not been sufficiently documented. Our patient responded favorably to treatment with continuous positive airway pressure during sleep, showing complete resolution of his symptoms. Timely diagnosis and management are fundamental to improve outcomes and prevent severe complications.

Factors Associated With Failure of Non-invasive Ventilation in Preterm Neonates Requiring Initial Respiratory Support

BACKGROUND

Non-invasive ventilation (NIV) modalities minimize the requirement for invasive mechanical ventilation (IMV) in preterm neonates, therefore improving neonatal outcomes, as IMV is linked to increased complications. However, NIV has demonstrated an elevated likelihood of failure, for which various studies have been done, but very little research is available addressing the factors that are responsible for NIV failure in resource-limited areas of developing nations. Understanding the underlying factors and their association with NIV failure in very and moderately preterm neonates at a tertiary care hospital would be important in devising targeted strategies to increase NIV success and newborn outcomes.

OBJECTIVE

To compare the following factors in neonates of 28-34 weeks gestational age with or without failure of NIV: fraction of inspired oxygen (FiO2) at the time of initiating NIV, time at surfactant administration, respiratory distress syndrome presence, antenatal steroid use, time taken for post-surfactant administration stabilization, gestational age, development of bronchopulmonary dysplasia, and average weight gained or lost.

STUDY DESIGN AND PARTICIPANTS

This was a longitudinal observational study. One hundred two preterm neonates with a gestational age of 28-34 weeks in the neonatal intensive care unit (NICU) requiring NIV support within 24 hours of admission.

METHODS

Eligible newborns were re-evaluated at 72 hours after commencing NIV. Outcome was evaluated as success (no NIV or NIV with positive end-expiratory pressure (PEEP)<8 cm H2O and FiO2<0.7) or failure (NIV with PEEP≥8 cm H2O or FiO2≥0.7, intubation, or death). It was compared with regard to many parameters.

RESULTS

 About 40 (39%) study participants reported NIV failure within 72 hours of initiating NIV. In the NIV failure group, male babies constituted 75% (P = 0.027), the median gestational age (IQR) was 29 (29-31) weeks (P = 0.015), the median birth weight (IQR) was 1088 (960-1293.5) grams (P = 0.003), and the median weight gain or loss (IQR) was a loss of 21 (-70.5 to 11.75) grams (P<0.001). Vaginal birth comprised 67.5% of the NIV failure group, showing greater failure rates than births out of lower segment cesarean section (LSCS) (P = 0.003) Conclusion: NIV failure showed a significant association with lesser gestational age, male sex, lower birth weight, vaginal method of delivery, and lesser weight gain during hospital stay.

Obstructive Sleep Apnea in Adults and Ear, Nose, and Throat (ENT) Health: A Narrative Review

Obstructive sleep apnea (OSA), a form of sleep-disordered breathing, is a significant health concern that leads to substantial morbidity. The collapse or occlusion of the upper airway, which results in reduced or cessation of airflow, is the pathophysiology of sleep apnea. The condition has been attributed to numerous cardiovascular, metabolic, and neuropsychological issues and carries serious health concerns. The ensuing intermittent hypoxia and sleep disruption set off a chain of physiological reactions that aid in developing endothelial dysfunction, systemic inflammation, and oxidative stress. The following line of treatment depends on the appropriate diagnosis of sleep apnea and the underlying cause. The gold standard for diagnosis is polysomnography (PSG), which assesses different physiological parameters during sleep. However, because polysomnography is expensive, patients may use more friendly screening and diagnostic testing kits, like home sleep apnea testing. The clinical symptoms and head and neck history may reveal essential risk factors. The primary objectives of management treatments for sleep apnea are to lessen symptoms, enhance sleep quality, and reduce any health concerns that may be present. It is advised to start with lifestyle changes such as quitting alcohol and sedative use, losing weight, and exercising frequently. The primary treatment for moderate to severe sleep apnea is continuous positive airway pressure (CPAP) therapy, which includes administering pressurized air to keep the airway open while you sleep. Oral appliances, positional therapy, surgery, and complementary therapies are other treatment choices that can be adapted to each patient's needs and preferences. The goal of the review is to evaluate the morphological and functional aspects of the upper airway, including the nose and throat, that influence the onset and severity of OSA. With a focus on the interaction between otorhinolaryngologists, sleep medicine specialists, and other healthcare professionals, we aim to consider how OSA affects otorhinolaryngology-related medical issues, look at any potential reciprocal relationships, and provide a summary of the interdisciplinary management strategy for OSA. We tried to analyse the various surgical and non-surgical therapy options for OSA management available in the otorhinolaryngology field for improving OSA symptoms and results.

Comparison of High Flow Nasal Cannula and Continuous Positive Airway Pressure in COVID-19 Patients With Acute Respiratory Distress Syndrome in Critical Care Unit: A Randomized Control Study

Background and objective Acute hypoxic respiratory failure in coronavirus disease 2019 (COVID-19) pneumonia has been treated with oxygen delivered by oxygen masks and non-invasive ventilation (NIV) with continuous positive airway pressure (CPAP), and more recently with high-flow nasal cannula (HFNC) devices. There is a paucity of randomized controlled trials to compare the efficacy of CPAP with HFNC in COVID-19 pneumonia. We conceptualized a randomized control study to compare the efficacy of HFNC and CPAP in reducing the need for invasive mechanical ventilation, estimation of mechanical ventilation-free days, and risk of intubation in COVID-19 patients with hypoxic respiratory failure. Methodology One hundred consecutive patients who satisfied the inclusion criteria were included in the trial. The patients were then randomly allocated to receive either CPAP or HFNC with settings as per the study protocol. The patients were deemed to have achieved the study endpoint when they were intubated due to any reason or successfully weaned from NIV to conventional oxygen therapies. The number of patients who required invasive ventilation and the number of invasive ventilation-free days were recorded and analyzed. Results Nineteen (38%) patients in the CPAP group and 30 (60%) patients in the HFNC group required invasive mechanical ventilation and the difference was statistically significant (p = 0.03, 95%CI: 0.1829-0.9129). The median number of days free of invasive mechanical ventilation in the CPAP group (median=5 (interquartile range (IQR(=5,6)) was more than in the HFNC group (median=4 (IQR=3,4)) and this difference was statistically significant (p<0.000). The secondary analysis of risk evaluation for intubation done using the Cox regression model showed no significant factors that could have contributed to intubation in the study population. The Kaplan-Meyer curve was used to express the probability of a patient getting intubated and the calculated hazard ratio was 2.29. Conclusion The administration of CPAP significantly reduced the intubation rate and prolonged invasive mechanical ventilation-free period in COVID-19 patients with hypoxic respiratory failure. We also inferred a two-fold increase in the risk of intubation in patients receiving HFNC compared to CPAP.

From Snoring to Soaring: Unveiling the Positive Effects of Continuous Positive Airway Pressure Ventilation on Cardiovascular Health in Patients With Obstructive Sleep Apnoea Through a Systematic Review

Increased cardiovascular (CV) morbidity and death are linked to obstructive sleep apnoea (OSA). The primary method of treating OSA is continuous positive airway pressure (CPAP). CPAP has some debatable outcomes on CV events in people suffering from OSA. The current study investigates how CPAP affects CV outcomes. The goal is to evaluate CPAP's effectiveness in lowering CV outcomes in OSA patients. We used a computer to search the PubMed, PubMed Central Library, Science Direct, and Google Scholar databases for studies comparing the effects of CPAP and a control group on CV outcomes in OSA patients. These included randomised control trials (RCT), narrative reviews, systematic reviews, case-control studies, observational studies and meta-analyses. A total of 52,937 patients were included in the final analysis of six RCTs, four observational studies, 10 meta-analyses, one case-control study, two systematic reviews and one narrative review. The weighted mean follow-up lasted for a period of between three months and nine years. The risk of major cardiovascular adverse events (MACE) was the same for both the CPAP and control groups. According to subgroup analysis, patients with lower MACE adherence rates (four hours per night) were more likely to use CPAP. The risk of all-cause mortality, CV-related complications causing mortality, acute myocardial infarction acute stroke, or hospitalisations for angina was the same in the CPAP and control groups. The primary outcome was that in patients with therapy with CPAP in addition to usual care and usual care alone did not prevent CV events in patients with moderate-to-severe OSA and existing CV illness. Patients with OSA who utilise CPAP may not experience fewer CV events. Patients who use CPAP consistently (four hours per night) could benefit from improved CV results. Future research must assess how well-adherent patients with severe OSA and low CV event rates respond to CPAP therapy. In patients who use CPAP for more than four hours each night, CPAP therapy may minimise the risk of MACE and stroke. Additional randomised trials requiring adequate CPAP time adherence are needed to support this perception. Despite the fact that there is no evidence to support the claim that CPAP therapy improves CV outcomes, bias difficulties, CPAP adherence problems, and the patient groups included in each RCT may have made it more difficult to generalise the findings to all patients. Future research is therefore needed to look at these relevant results.

Neck Swelling With Valsalva

We present a rare case of bilateral pharyngocoeles in a patient with symptomatic neck swelling prominently seen with the Valsalva manoeuvre. Pharyngocoeles have only been reported a handful of times in the literature. Due to their rarity, they can easily be misdiagnosed as a laryngocoele, Zenker's diverticulum, or jugular venous phlebectasia. The diagnosis in this case was confirmed on computed tomography imaging of the neck with Valsalva performed. Our patient underwent surgical excision of the symptomatic pharyngocoele on the right side while conservative management was opted for the asymptomatic left pharyngocoele. His risk factors for developing bilateral pharyngocoeles are most likely due to the use of continuous positive airway pressure (CPAP) machine at high pressures coupled with pharyngeal wall weakness. To our knowledge, this is the first case of pharyngocoeles associated with CPAP machine use. It is important to perform a thorough assessment to appropriately diagnose and treat patients with this anatomical anomaly.

Effectiveness of Continuous Positive Airway Pressure in Treating Hypertension in Obstructive Sleep Apnea: A Traditional Review

Almost one billion individuals worldwide suffer from obstructive sleep apnea (OSA). The most widely used treatment for OSA has been continuous positive airway pressure (CPAP), but its effect on blood pressure (BP) has been challenged. Our review aims to evaluate the effects of treating OSA with CPAP on BP and BP-related morbidities in adult hypertensive patients. Medical subject headings (MeSH) terminology was used to search the PubMed Central, MEDLINE, and PubMed databases for articles on the use of CPAP in OSA patients with hypertension. We selected various forms of academic writing, encompassing complete texts that were published in the English language. The study included a total of 21 papers. OSA is a serious health concern associated with a higher risk of cardiovascular disease, kidney disease, pulmonary hypertension, and aortic stiffness, which is brought on by the periodic hypoxia caused by nocturnal respiratory episodes. For individuals with moderate-to-severe OSA, CPAP therapy has been shown to have a considerable long-term benefit with a median drop of 11 mm Hg, and high adherence results in a decrease in diastolic BP. CPAP therapy directly lowers BP in OSA patients with a body mass index (BMI) of more than 30 kg/m2 and has also demonstrated improvement in early signs of atherosclerosis with lower nocturnal systolic BP levels. OSA patients with resistant hypertension also experienced lower BP after using CPAP for a year. Therefore, our findings suggest that obesity, hypersomnolence, high nocturnal BP, prolonged CPAP usage, and resistant hypertension may all have a major impact on the BP response to CPAP therapy in individuals with severe OSA.

Inhalation Pneumonitis Caused by Nebulized Hydrogen Peroxide

Hydrogen peroxide is a chemical commonly used as a household antiseptic for cleaning and disinfecting. No cases of acute hydrogen peroxide inhalation-induced lung injury are previously described. We present a case of acute chemical pneumonitis caused by mixing hydrogen peroxide in a nighttime continuous positive airway pressure device's humidifier used for obstructive sleep apnea to prevent COVID-19 infection. The patient endorsed mixing hydrogen peroxide with distilled water in his nighttime continuous positive airway pressure device's humidifier at a ratio of 1:3-1:2 for the previous week before admission based on a friend's advice in preventing COVID-19. The presenting chest X-ray showed new multifocal consolidations with interstitial markings and alveolar edema throughout both lungs. Chest computed tomography (CT) imaging demonstrated multifocal, bilateral, hazy consolidations with increased interstitial markings and bilateral pleural effusions. The patient was subsequently initiated on systemic glucocorticoid therapy, significantly improving hypoxemia and dyspnea. Inhalation of hydrogen peroxide may produce acute pneumonitis distinct from what has been described previously with chronic inhalation. Given this case, systemic glucocorticoid therapy may be considered a viable treatment option for acute hydrogen peroxide-associated inhalation lung injury causing pneumonitis.

Benefits in quality of life following an obstructive sleep apnea screening and treatment program in patients with acute ischemic stroke

INTRODUCTION

Obstructive sleep apnea (OSA) has been proposed as a factor that worsens stroke prognosis. Our aim was to determine if an OSA intervention could improve quality of life (QOL, first objective) and modified Rankin score (mRS, second objective).

PATIENTS AND METHODS

The intervention group of this quasi-experimental study included patients with acute ischemic stroke <72 hours who underwent polygraphy and Continuous Positive Airway Pressure (CPAP) and hygienic-dietary measures if required. The control group followed routine clinical practice. The Short Form 36 Health Survey (SF-36) and mRS were applied at the sixth month after stroke in both groups.

RESULTS

Fifty-five vs. sixty-two patients were included in the intervention and control group respectively. In the intervention group, 64.71% of patients accepted the proposed CPAP (16 cases with a good adherence). An improvement in SF-36 items was detected in the intervention group: physical functioning (p = 0.008), role physical (p = 0.002), bodily pain (p = 0.008), general health (p <0.001), vitality (p = 0.001) and role emotional (p = 0.015). In a per-protocol analysis, all these improvements were verified in the group of patients treated with good CPAP adherence (p < 0.05 in all the same SF-36 items). The percentage of patients with physical component summatory = 50 was higher in the intervention group (p = 0.003). There were no differences in the median of mRS (p = 0.262).

CONCLUSIONS

Although more evidence is needed, a significant improvement in QOL was suggested after our OSA intervention, particularly in patients with good CPAP adherence.

Severe Legionella and Histoplasma Pneumonia Acquired From Spring Water

Legionnaires' disease and pulmonary histoplasmosis are important causes of community-acquired pneumonia. Environmental reservoirs remain the primary source of infection and may persist since investigations are often reserved for large outbreaks. Our case highlights a source of both legionella and histoplasmosis not previously reported. It demonstrates the value of taking a thorough history while recognizing non-traditional sources of both infections.

Transition from APAP to CPAP may be a cost-effective health intervention in OSA patients

OBJECTIVE

Obstructive sleep apnea (OSA) is a common disorder associated with a significant economic burden. Continuous positive airway pressure (CPAP) and auto-titrating positive airway pressure (APAP) are recognized therapeutic options in patients with OSA, although treatment costs are higher with APAP. We conducted a study aimed at evaluating the effectiveness and potential cost savings resulting from the implementation of a protocol guiding the transition to CPAP in OSA patients previously treated with APAP.

METHODS

This prospective study included patients with OSA under APAP who were followed up at the Sleep Medicine outpatient clinic of a tertiary referral hospital between January 2019 and January 2021. Treatment was switched to CPAP in patients who met the following criteria: satisfactory adaptation and adherence to APAP, residual apnea-hypopnea index (AHI) of < 5/hour, and no relevant air leaks. APAP and CPAP outcomes were compared and an estimate of the savings obtained by the transition from APAP to CPAP was calculated.

RESULTS

Ninety-three patients were included in the study. APAP and CPAP were both effective in correcting obstructive events and improving daytime sleepiness. No significant differences were found regarding treatment adherence and tolerance between both PAP modalities. The selection of fixed-pressure CPAP through 90th or 95th percentile APAP pressure proved to be effective and an alternative strategy to titration polysomnography. At the end of this two-year study, the transition from APAP to CPAP enabled savings of at least 10,353€.

CONCLUSION

The transition from APAP to CPAP may be an effective, well-tolerated, safe, and cost-saving strategy in patients with OSA.

The Many Fronts of Battling Obstructive Sleep Apnea

Obstructive sleep apnea (OSA) is a breathing disorder during sleep secondary to collapsing upper airways that leads to a significant decrease or a complete cessation of airflow despite an effort to breathe. As the name suggests, an obstruction, likely caused by an inherited narrow airway, is the most common cause. But there are less known factors that may contribute to the worsening of OSA. We present a case of very severe OSA contributed by weight gain, opioid use, and anterior cervical discectomy and fusion (ACDF), in addition to a genetically narrow airway. This case highlights the importance of battling OSA on many different fronts. Our patient eventually was able to stop positive airway pressure (PAP) therapy, once the contributing factors were addressed appropriately.

An Updated Review on the Relationship of Depressive Symptoms in Obstructive Sleep Apnea and Continuous Positive Airway Pressure

Obstructive sleep apnea (OSA) is a common sleep disorder occurring across all age groups, gender, and is multifactorial. The episodic decrease in airflow during sleep results in hypoxia and hypercapnia over time, resulting in morning headache, systemic and pulmonary hypertension, and polycythemia. Fragmentation of sleep at night-time cause daytime somnolence, fatigue, memory problems, and mood symptoms such as depression and anxiety. These secondary mood symptoms could be easily missed by healthcare providers as the primary disorder resulting in unnecessary anti-depressants' prescription. This study investigates the effect of continuous airway pressure (CPAP) on depressive symptoms of OSA. We used PubMed, PubMed Central (PMC), and MEDLINE for data collection. We used OSA, depression, anxiety, mood symptoms, psychological symptoms, and CPAP as the keywords, both alone and in combination. The search ended on November 5, 2020, and it was limited to the year 2010 until the day of the search. However, a few of the papers published earlier than 2010 were also included to have better insight into some aspects of the topic. We included articles measuring the impact of CPAP on mood symptoms using any one of the validated scales, such as the Beck Depression Inventory (BDI), the State-Trait Anxiety Inventory (STAI), Hospital Anxiety and Depression Scale (HADS), or Hamilton Depression Scale (HAM-D). Our initial searches yielded 131 articles. Twenty-one of the 131 papers satisfied the review's criteria. Four studies out of 21 revealed no improvement in OSA-related mood symptoms with CPAP therapy, whereas the others reported beneficial effects on mood, daytime sleepiness, cognition, and patient quality of life.

Cognitive Impairment and Depressive Symptoms in a Patient With Obstructive Sleep Apnea: Full Recovery After CPAP Treatment

Obstructive sleep apnea syndrome (OSA) is associated with neuropsychiatric symptoms, including cognitive impairment and depression. It is important to be aware of this association since these comorbid symptoms may be misdiagnosed as a primary psychiatric condition. We report a case of a 60-year-old man with depressive symptoms and cognitive impairment, with important deficits in memory and great functional impairment. There was no response to many antidepressant trials and, later, he underwent polysomnography and was diagnosed with severe OSA. The patient started treatment with continuous positive airway pressure (CPAP) and showed progressive improvement in depressive and cognitive symptoms. During one year of follow-up, there was no recurrence of psychiatric symptoms and the patient was able to stop antidepressants and to recover his functionality. This case highlights the importance of searching for OSA signals when assessing patients with depressive and cognitive symptoms, since they may improve with OSA adequate treatment.

Diagnosis and management of childhood sleep-disordered breathing. Clinical approach

Sleep-disordered breathing (SDB) includes disorders of breathing that affect airway patency, which impair children's sleep and lead to negative consequences. Obstructive sleep apnea, hypoventilation and upper airway resistance syndrome are common causes of morbidity and mortality in childhood. These clinical practice guidelines, intended for use by pediatricians and primary care clinicians, provide a clear recommendation for the diagnosis and management of sleep-disordered breathing, focusing on the most serious disorder, obstructive sleep apnea syndrome (OSAS). These clinical guidelines formulate clear recommendations to identify patients with suspected OSAS. Further, the manuscript will highlight the potential consequences of SBD in children, and how to overcome such difficulties, what could be the therapeutic options, a 12 recommendations and what are the future direction for pediatric sleep medicine.

Induction of General Anesthesia and Mask Ventilation With a Full-Face Continuous Positive Airway Pressure Mask in a Patient With a Nose Deformity

Mask ventilation (MV) is an essential component of airway management and can be lifesaving in situations where the placement of a secure airway device proves challenging. Effective MV requires a seal to be created between the mask and the face to maintain patency of the external airway structures and can be difficult in the setting of facial abnormalities or facial trauma. Here we describe a case in which a continuous positive airway pressure (CPAP) mask was used for anesthesia induction and MV in an 85-year-old man who underwent a plastic surgery reconstruction of the left nasal dorsum and ala following a Mohs surgery, which had prevented the use of conventional face mask. An effective seal was achieved, and anesthesia was successfully induced with the mask. We reviewed the literature and discussed alternative approaches for face mask use in the setting of facial abnormalities where the use of a conventional mask is unfeasible.

Obstructive Sleep Apnea and Hypertension: A Review of the Relationship and Pathogenic Association

Obstructive sleep apnea (OSA) is defined as episodes of hypopnea or apnea, which leads to a partial or complete block of airways. Hypertension, on the other hand, is defined as an increase in systemic arterial blood pressure to a certain threshold. OSA and hypertension share many common factors in pathophysiology, such as gender, obesity, unhealthy lifestyle, impaired quality of sleep, renin-angiotensin system, and increased fluid distribution. In order to manage our patients effectively, we need to explore further the correlation between the two conditions.

Obstructive sleep apnea syndrome and asthma: what are the links?

Recent data suggest that obstructive sleep apnea syndrome (OSAS) is an independent risk factor for asthma exacerbations. Neuromechanical reflex bronchoconstriction, gastroesophageal reflux, inflammation (local and systemic), and the indirect effect on dyspnea of OSAS-induced cardiac dysfunction have been suggested as mechanisms that lead to worsening asthma control in patients with concomitant OSAS. Vascular endothelial growth factor-induced airway angiogenesis, leptin-related airway changes, and OSAS-induced weight gain also may play a common mechanistic role linking both disorders. Several studies have confirmed that asthmatic patients are more prone to develop OSAS symptoms than are members of the general population. The common asthmatic features that promote OSAS symptoms are nasal obstruction, a decrease in pharyngeal cross sectional area, and an increase in upper airway collapsibility. Clarifying the nature of the relationship between OSAS and asthma is a critical area with important therapeutic implications.