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Substance use disorders (SUDs) are associated with profound sleep disturbances, including insomnia, sleep fragmentation, and circadian rhythm dysfunction resulting in serious mental and physical consequences. This minireview presents an overview of the neurocircuitry underlying sleep disturbances in SUDs and elaborates on treatment options with emphasis on alcohol use disorder (AUD) and opioid use disorder (OUD). A PubMed, Embase, CINAHL Plus, Cochrane, and Scopus search were conducted using sleep- and AUD/OUD related keywords from January 1st, 2000, to January 31st, 2023, with preferences for recent publications and randomized-controlled trials. A bidirectional relationship exists between insomnia and addiction with the status of each condition impacting the other in dictating clinical outcome. Existing evidence points to a resurgence of insomnia during detoxification, and unless treated satisfactorily, insomnia may lead to relapse. The discussion summarizes the strengths and limitations of cognitive behavioral therapy and pharmacological treatment for insomnia in SUDs covering evidence from both animal and clinical studies. The assumption of reestablishing normal sleep patterns by attaining and maintaining sobriety is misguided. Comorbid insomnia in patients with SUDs should be approached as an independent condition that requires its own treatment. Future clinical trials are needed with the aim of providing a resource for guiding clinical management of the many patients with insomnia and SUD. [ABSTRACT FROM AUTHOR]

Purpose: The causes of residual excessive sleepiness (RES) in patients with post-traumatic stress disorder (PTSD) and obstructive sleep apnea (OSA) are multifactorial and modulated by comorbid conditions. The aim of the present study was to elucidate clinical and polysomnographic determinants of RES in continuous positive airway pressure (CPAP)-adherent OSA veterans with PTSD. Methods: The study protocol consisted of a retrospective analysis of consecutive cases of patients with PTSD who presented to the Veterans Affairs sleep clinics with adequately treated OSA between June 1, 2017 and October 15, 2021. Based on the Epworth Sleepiness Scale (ESS), patients were categorized into RES (ESS ≥ 11) and no RES (ESS < 11) groups. Demographic and PSG data were subjected to univariate and multivariate analyses to ascertain predictive factors of RES. Results: Out of 171 veterans with PTSD who were adherent to CPAP, 59 (35%) continued to experience RES. The RES group had a decrease in mean ESS score of 1.2 ± 4.5 after CPAP treatment compared with 4.6 ± 4.9 for the no RES group (< 0.001). A dose–response was observed between CPAP use and RES (p = 0.003). Multivariate regression analysis identified higher baseline ESS (OR 1.30; 95% CI 1.16–1.44), greater percentage of time spent in REM sleep (OR 0.91; 95% CI 0.85–0.96), CPAP use less than 6 h (OR 2.82; 95% CI 1.13–7.01), and a positive screen for depression (OR 1.69; 95% CI 1.03–4.72) as independent predictors of RES in patients with PTSD and OSA. Conclusion: RES is highly prevalent in patients with PTSD and OSA despite adherence to CPAP and is independently associated with percentage time spent in REM, duration of CPAP utilization, and symptoms of depression. [ABSTRACT FROM AUTHOR]

Purpose: Severe community-acquired pneumonia (CAP) requiring intensive care unit admission is associated with significant acute and long-term morbidity and mortality. We hypothesized that downregulation of systemic and pulmonary inflammation with prolonged low-dose methylprednisolone treatment would accelerate pneumonia resolution and improve clinical outcomes. Methods: This double-blind, randomized, placebo-controlled clinical trial recruited adult patients within 72–96 h of hospital presentation. Patients were randomized in 1:1 ratio; an intravenous 40 mg loading bolus was followed by 40 mg/day through day 7 and progressive tapering during the 20-day treatment course. Randomization was stratified by site and need for mechanical ventilation (MV) at the time of randomization. Outcomes included a primary endpoint of 60-day all-cause mortality and secondary endpoints of morbidity and mortality up to 1 year of follow-up. Results: Between January 2012 and April 2016, 586 patients from 42 Veterans Affairs Medical Centers were randomized, short of the 1420 target sample size because of low recruitment. 584 patients were included in the analysis. There was no significant difference in 60-day mortality between the methylprednisolone and placebo arms (16% vs. 18%; adjusted odds ratio 0.90, 95% CI 0.57–1.40). There were no significant differences in secondary outcomes or complications. Conclusions: In patients with severe CAP, prolonged low-dose methylprednisolone treatment did not significantly reduce 60-day mortality. Treatment was not associated with increased complications. [ABSTRACT FROM AUTHOR]

Statins have been advocated as a potential treatment for coronavirus disease-2019 (COVID-19) due to its pleotropic properties. The aim of the study was to elucidate the association between antecedent statin exposure and 30-day all-cause mortality, intensive care unit (ICU) admission and hypoxic respiratory failure requiring mechanical ventilation in patients diagnosed with COVID-19. Observational cohort study derived from the VA Corporate Data Warehouse of all veterans tested positive for COVID-19 between January 1st and May 31st, 2020. Antecedent use of statins was defined as a redeemed drug prescription in the 6 months prior to COVID-19 diagnosis. Propensity-matched mixed-effects logistic regression was performed, stratified by statin use. The study population comprised 14,268 patients with COVID-19 (median age 66 years (25th–75th percentile, 53–74), 90.7% men), of whom 7,168 were receiving a prescription for statins. Patients with statin exposure had a greater prevalence of comorbidities and a higher risk of mortality (Odd ratio [OR] 1.52; 95% confidence interval [CI] 1.37–1.68). After adjusting for covariates, statin exposure was not associated with a decreased mortality in the overall cohort by either Cox proportional hazards stratified model (HR 0.99; 95% CI 0.88–1.12) or propensity matching (HR.86; 95% CI 0.74–1.01). Similarly, there was no demonstrated advantage of statins in reducing the risk of ICU admission (HR 0.92; 95% CI 0.74–1.31) or hypoxic respiratory failure requiring mechanical ventilation (HR 1.02; 95% CI 0.81–1.29). Antecedent statin exposure in patients with COVID-19 was not associated with a decreased risk of 30-day all-cause mortality or need for mechanical ventilation. [ABSTRACT FROM AUTHOR]

Purpose: We sought to determine the prevalence of low arousal threshold (LAT) in veterans with post-traumatic stress disorder (PTSD) and whether or not LAT is associated with decreased use of continuous positive airway pressure (CPAP). Methods: We conducted a retrospective study of all veterans with documented PTSD who had an apnea hypopnea index > 5/h over a 27-month period. Demographic, clinical characteristics, and CPAP usage were extracted from the medical records. A multivariate analysis was conducted to assess predictors of CPAP use at 3 months in patients with LAT after adjusting for severity of PTSD. Results: LAT was identified in 55% of 119 patients with PTSD and newly diagnosed OSA. LAT was associated with younger age (odds ratio [OR] 0.91; 95% confidence interval [CI] 0.86–0.95), lower BMI (OR 0.82; 95% CI 0.73–0.91), presence of insomnia (OR 1.34; 95% CI 1.19–1.81), and use of antidepressant (OR 1.14; 95% CI 1.09–2.01). PTSD severity, REM rebound, and the presence of baseline comorbid insomnia were each associated with CPAP use at 3 months. Neither daytime sleepiness, body mass index (BMI), nor LAT endotype was correlated with CPAP utilization. Insomnia was the only factor associated with decreased CPAP use in patients with PTSD and LAT (P = 0.04). Conclusion: The LAT endotype is common among veterans with PTSD. An improved understanding of how insomnia in this population affects CPAP utilization would be instrumental in designing targeted therapy to improve sleep quality. [ABSTRACT FROM AUTHOR]

Increasingly compelling data link chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA) to cardiovascular complications independent of known comorbidities. It remains unclear whether the association is amplified in the presence of both conditions. The aims of this study are to assess the prevalence of atrial fibrillation (AF) in overlap syndrome (OS) and to identify risk factors predisposing to this atrial arrhythmia. We conducted a retrospective cohort study of 268 adults without past or current AF who were referred for an initial diagnostic polysomnogram from 2012 to 2019. A logistic regression analysis was performed to identify risk factors for incident AF. Incident AF occurred in 64 subjects [cumulative probability 24%, 95% confidence interval (CI) 19-29]. Independent predictors of incident AF were age-adjusted Charlson index [Odds ratio (OR) 1.62; 95% confidence interval (CI) 1.3-2.0], percentage of time spent with O2 saturation below 90% (CT90) (OR 3.72, 95% CI 1.18-11.71), and CPAP adherence (OR 0.32, 95% CI 0.13-0.71). OS patients with AF experienced higher hospitalization rates (OR 1.25, 95% CI 1.03-2.37) and worse mortality rates (OR 1.92, 95% CI 1.04-3.54). In multivariate Cox proportional regression, age-adjusted Charlson Index, severity of airflow obstruction, and CPAP adherence were independent predictors of mortality. The burden of hypoxemia and severity of comorbidities are independent factors for incident AF in individuals with OS. CPAP adherence may mitigate the risk of AF and reduce the rate of mortality in this population. [ABSTRACT FROM AUTHOR]

Background: Insomnia is a well-recognized co-morbid condition in veterans with post-traumatic stress disorder (PTSD) with negative personal and social consequences. Cognitive behavioral therapy (CBT) is considered an efficacious treatment, yet little attention has been devoted to treatment response in this population. The aim of this study was to identify factors that may predict clinical response to CBT for insomnia (CBT-I) in veterans with PTSD. Methods: A retrospective chart review of 136 veterans with PTSD-related insomnia was conducted. Epworth Sleepiness Score (ESS), PTSD Checklist (PCL), and Insomnia Severity Index (ISI) were assessed at baseline. We converted prescribed antidepressant and hypnotic dosages before and after CBT-I to dose equivalent of fluoxetine diazepam, respectively. A 6-point reduction or greater in ISI scores at 6-month follow-up visit was defined as CBT-I responsiveness. Results: CBT-I responsiveness was observed in 47% of veterans with PTSD. Seventy-seven percent completed treatment. Lack of perceived benefit was the most given reason for failure to return for follow-up. In contrast to hypnotics, antidepressants usage decreased in those who had experienced benefit from CBT-I (p = 0.001). Younger age, non-white race, and use of hypnotics prior to behavioral therapy were independently associated with lack of response to CBT-I. Conclusions: While CBT-I ameliorates insomnia in veterans with PTSD, the use of hypnotics prior to instituting behavioral therapy may negatively affect the response rate to CBT-I. Future studies should examine whether racial and cultural influences on the generation of insomnia in veterans with PTSD affects the response to CBT-I. [ABSTRACT FROM AUTHOR]

Purpose: The purpose of this study was to determine the impact of insomnia in Veterans with post-traumatic stress disorder (PTSD) and obstructive sleep apnea (OSA) on health-related outcomes before and after 12 weeks of continuous positive airway pressure (CPAP) treatment.Methods: We conducted a prospective cohort study of Veterans with PTSD and documented apnea hypopnea index (AHI) ≥ 5 with and without clinically significant insomnia as determined by the Insomnia Severity Index (ISI). Health-related outcomes including PTSD checklist (PCL-M), SF-36, and Pittsburgh Sleep Quality Index (PSQI) were assessed at baseline and 12 weeks after initiation of OSA treatment. CPAP adherence was retrieved at each visit.Results: Seventy-two Veterans including 36 with comorbid insomnia and OSA (COMISA) and 36 OSA-only were enrolled. Veterans with COMISA were younger (p = 0.03), had lower BMI (p < 0.001), and were more likely to report depression than those with OSA-only (p = 0.004). Although AHI was higher in the COMISA (p = 0.01), both groups expressed comparable daytime sleepiness (p = 0.16). The COMISA group had no significant change in SF-36 and PSQI after 12 weeks of treatment and used CPAP much less frequently than OSA-only group (p = 0.001).Conclusions: COMISA in Veterans with PTSD is associated with worse quality of life than those with OSA-only. Insomnia should be assessed in Veterans with PTSD who are not adherent to CPAP treatment. [ABSTRACT FROM AUTHOR]

The use of nasal high-flow oxygen therapy (NHFOT) has become increasingly common in hospitals across Europe, Asia, and North America. These high utility devices provide an efficient and comfortable access points for providing supplemental oxygen to patients with variety of respiratory disorders. They are relatively easy to set up, and clinicians and patients alike give very positive feedback about their ease of use and comfort for patients in the hospital setting. However, it remains uncertain whether NHFOT improves patient survival or even reduces respiratory complications. Outcome data in adult populations are few and frequently underpowered to guide physicians for their widespread use in hospital setting. In this article, we present a review of the current technology and available studies pertinent to NHFOT. [ABSTRACT FROM AUTHOR]

The practice of sedation dosing strategy in mechanically ventilated patient has a profound effect on cognitive function. We conducted a comprehensive review of outcome of sedation on mental health function in critically ill patients on mechanical ventilation in the intensive care unit (ICU). We specifically evaluated current sedative dosing strategy and the development of delirium, post-traumatic stress disorders (PTSDs) and agitation. Based on this review, heavy dosing sedation strategy with benzodiazepines contributes to cognitive dysfunction. However, outcome for mental health dysfunction is mixed in regard to newer sedatives agents such as dexmedetomidine and propofol. Moreover, studies that examine the impact of sedatives for persistence of PTSD/delirium and its long-term cognitive and functional outcomes for post-ICU patients are frequently underpowered. Most studies suffer from low sample sizes and methodological variations. Therefore, larger randomized controlled trials are needed to properly assess the impact of sedation dosing strategy on cognitive function. [ABSTRACT FROM AUTHOR]

Background: Patients with the combination of chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA), known as the 'overlap syndrome,' have a substantially greater risk of morbidity and mortality compared to those with either COPD or OSA alone. The study's objective was to report on the long-term outcome of hypercapnic (PaCO ≥ 45 mmHg) and normocapnic patients with the overlap syndrome treated with continuous positive airway pressure (CPAP). Methods: A nonconcurrent cohort of consecutive patients with the overlap syndrome was followed for a median duration of 71 months (range 1-100) at a VA sleep center. All patients were managed according to the prevailing recommendations of both diseases. The end point of the study was all-cause mortality. Results: Of the 271 patients identified, 104 were hypercapnic (PaCO = 51.6 ± 4.3 mmHg). Both normocapnic and hypercapnic patients had comparable apnea-hypopnea indexes (AHI) (29.2 ± 23.8 and 35.2 ± 29.2/h, respectively; p = 0.07) and similar adherence rates to CPAP (43 and 42 %, respectively, p = 0.9). Survival analysis revealed that hypercapnic patients who were adherent to CPAP had reduced mortality compared to nonadherent hypercapnic patients ( p = 0.04). In contrast, the cumulative mortality rate for normocapnic patients was not significantly different between the adherent and the nonadherent group ( p = 0.42). In multivariate analysis, the comorbidity index was the only independent predictor of mortality in normocapnic patients with the overlap syndrome [hazard ratio (HR) 1.68; p < 0.001] while CPAP adherence was associated with improved survival (HR 0.65; p = 0.04). Conclusions: CPAP mitigates the excess risk of mortality in hypercapnic patients but not in normocapnic patients with the overlap syndrome. [ABSTRACT FROM AUTHOR]

Antimicrobial therapy has been the main stay of therapy of community-acquired aspiration pneumonia (CAAP), but the duration of treatment has not been established. The objective of this study was to describe the time to reach clinical stability in patients with aspiration pneumonia compared to community-acquired pneumonia (CAP). A retrospective case control study at two university affiliated centers encompassing 329 consecutive patients admitted with CAAP and 329 consecutive patients with CAP was conducted between 2007 and 2011. While the median time to stability for patients with CAP was distributed around a median of 4 days, there was a bimodal distribution for time to clinical stability in patients with CAAP with dual peaks at days 2 and 5, respectively. CAAP patients who required more than 2 days to achieve clinical stability had a higher mortality rate compared to those with 2 days or less [odds ratio (OR) 5.95, 95% CI 2.85-12.4], and a longer hospital stay (6.6 ± 5.8 vs. 3.9 ± 1.2 days; p < 0.001). None of the CAAP patients who achieved clinical stability in 2 days or less was transferred to a higher level of care. In a multivariate analysis, time to clinical stability was found to be an independent predictor of outcome in patients with CAAP (OR 2.59, 95% CI 2.02-3.32). Normalization of vital signs in aspiration pneumonia follows a distinct pattern from that of patients with CAP. Time to achieve clinical stability may assist in identifying CAAP patients who are likely to require a shorter hospital stay and a shorter course of antimicrobial therapy. [ABSTRACT FROM AUTHOR]

Background: Obstructive sleep apnea (OSA) has been linked to chronic inflammation and cardiovascular diseases. Considerable evidence suggests that innate immune defense mechanisms might interact with proinflammatory pathways and contribute to atherogenesis. We hypothesized that the classical pathogen recognition receptors of the innate immune response, Toll-like receptors, are involved in modulating the inflammatory response in OSA. Methods: Expression of TLR2 and TLR4 on circulating monocytes from 29 subjects with documented OSA and 18 controls were compared with the use of flow cytometry and reverse transcription-polymerase chain reaction at baseline and after 8 weeks of continuous positive airway pressure (CPAP). Results: There was a significant increase in both TLR2 and TLR4 surface expression and mRNA levels on monocytes after adjustment for age, body mass index, and waist-to-hip ratio. This was paralleled by enhanced nuclear factor-κB nuclear binding and an increased release of IL-6, INF-γ, and TNF-α in OSA versus control subjects. Following 8 weeks of treatment, continuous positive airway pressure downregulated TLR2 and TLR4 expression and abrogated the release of inflammatory cytokines. Conclusion: OSA is associated with enhanced expression and signaling events downstream of TLR2 and TLR4 in circulating monocytes. These observations are mitigated by CPAP therapy, which suggest that TLR2 and TLR4 activation may be involved as a signaling mechanism in immune-mediated progression of atherosclerosis in OSA. [ABSTRACT FROM AUTHOR]

Background: The objective of this study was to perform a systematic review and meta-analysis of the impact of the 2005 American Thoracic Society/Infectious Diseases Society of America guideline-concordant antimicrobial therapy (GCAT) on mortality following healthcare-associated pneumonia (HCAP). Methods: We searched MEDLINE, EMBASE, BIOSIS, Cochrane CENTRAL Register of Controlled Trials, and Scopus for clinical trials and observational studies comparing GCAT to other treatment regimens in adults with HCAP. The primary outcome chosen was 30-day mortality from any cause. Secondary outcomes assessed length of hospital stay and time to clinical stability. Random effects models were used to generate pooled odds ratios (ORs) and weighed mean differences (WMDs). Heterogeneity was evaluated by the I. Results: A total of six studies were included in the analysis and involved 15,850 participants. Meta-analysis showed that GCAT was associated with increased 30-day mortality compared to non-GCAT (OR 1.80, 95 % confidence interval [CI] 1.26-2.7). There was no advantage in GCAT over non-GCAT in terms of hospital length of stay (WMD 1.18 days, 95 % CI −0.48 to 2.84) or time to clinical stability (WMD 0.17 days, 95 % CI −0.32 to 0.67). Conclusion: In hospitalized patients with HCAP, GCAT did not show survival benefit compared to non-GCAT. However, our results are limited by the cohort design of the selected studies and the degree of heterogeneity among them. Future trials are needed to identify risk factors for multidrug-resistant pathogens in HCAP patients who may benefit from broad-spectrum antimicrobial regimens. [ABSTRACT FROM AUTHOR]

Study objectives: This study was conducted to determine whether postoperative complications are increased in patients with obstructive sleep apnea (OSA) and to study the impact of the severity of OSA and preoperative use of continuous positive airway pressure (CPAP) on the postoperative outcome. Design and setting: This study is retrospective in nature and was undertaken at the VA Medical Center. Participants and methods: Three hundred seventy patients who had undergone both a major surgical procedure and a sleep study from 2000 to 2010 were identified. Patients were divided into four groups: OSA negative (apnea-hypopnea index (AHI) < 5/h), OSA positive; mild: AHI 5 to <15/h; moderate: AHI 15 to <30/h; and severe: AHI ≥ 30/h. No intervention was made during the course of the study. Postoperative complications namely respiratory, cardiac, neurological, and unplanned intensive care unit transfers were collected. Results: There were 284 (76.8 %) patients having OSA and 86 (23.2 %) without OSA. The overall incidence of total complications was significantly higher in the OSA patients compared with the control patients (48.9 vs. 31.4 %; odds ratio 2.09, 95 % CI 1.25-3.49). There was no significant difference in total complications between those using and not using CPAP prior to hospitalization. Patients with sleep apnea had a higher incidence of respiratory complications compared to patients without sleep apnea (40.4 vs. 23.2 %; odds ratio 2.24, 95 % CI 1.29-3.90). There was no significant difference in major cardiac complications in the OSA patients compared with the control patients (13.0 vs. 9.3 %; odds ratio 1.46, 95 % CI 0.65-3.26). Conclusion: OSA is associated with a significantly increased rate of postoperative complications. [ABSTRACT FROM AUTHOR]

Purpose: Clinical and epidemiologic investigations suggest a strong association between obesity and obstructive sleep apnea (OSA). The purpose of this study is to evaluate the currently available literature reporting on the effectiveness of dietary weight loss in treating OSA among obese patients. Methods: Relevant studies were identified by computerized searches of PubMed, EMBASE, CINAHL, Web of Science, and The Cochrane Central Register of Controlled Trials through September 2011 as well as the reference lists of all obtained articles. Information on study design, patient characteristics, pre- and post-dietary weight loss measures of OSA and body mass index (BMI), and study quality was obtained. Data were extracted by two independent analysts. Weighted averages using a random-effects model are reported with 95 % confidence intervals. Results: Nine articles representing 577 patients were selected. Dietary weight loss program resulted in a pooled mean BMI reduction of 4.8 kg/m (95 % confidence interval [CI] 3.8-5.9). The random-effects pooled apnea hypopnea (AHI) indices at pre- and post-dietary intervention were 52.5 (range 10.0-91.0) and 28.3 events/h (range 5.4-64.5), respectively ( p < 0.001). Compared to control, the weighted mean difference of AHI was decreased by −14.3 events/h (95 % CI −23.5 to −5.1; p = 0.002) in favor of the dietary weight loss programs. Conclusions: Dietary weight loss programs are effective in reducing the severity of OSA but not adequate in relieving all respiratory events. Weight reduction programs should be considered as adjunct rather than curative therapy. [ABSTRACT FROM AUTHOR]

Objectives: To assess the validity of a handheld clinical decision-support system (CDSS) in detecting obstructive sleep apnea (OSA) in veterans with ischemic heart disease against polysomnography (PSG) and to compare the diagnostic accuracy of the CDSS versus the Berlin questionnaire. Methods: We enrolled prospectively 143 patients with underlying ischemic heart disease. Veterans with history of neurologic disease, systolic congestive heart failure, or receiving opiates were excluded from participation. Participants were asked to complete the Berlin Questionnaire and to answer all eight questions of CDSS-software. At the end of the interview, veterans were scheduled for an in-laboratory polysomnogram. Results: Ninety one patients completed the study. The prevalence of OSA (AHI ≥5/h) was 74.7 % with a median AHI of 11.5/h (range 0-90). When compared to PSG, the CDSS and the Berlin questionnaire achieved a sensitivity of 98.5 % [95 % confidence interval (CI) 92.1-100] and 80.9 % (95 % CI 69.5-89.4) and a specificity of 86.9 % (95 % CI 66.4-97.2) and 39.1 % (95 % CI 19.7-61.5) at a threshold value of AHI ≥5 with a corresponding area under the curve of 0.93 (95 % CI 0.85-0.97) and 0.60 (95 % CI 0.49-0.70); respectively. Conclusions: CDSS is a superior screening tool for identifying cardiac veterans with undiagnosed OSA than the BQ. [ABSTRACT FROM AUTHOR]

Obstructive sleep apnea (OSA) is a prevalent disorder often associated with daytime sleepiness, cognitive dysfunction, and adverse cardiovascular consequences. Available therapies are limited by either lack of long-term adherence or low response rates. Two emerging therapies hold promise in providing alternatives to patients with OSA. The first stems from the importance of the upper-airway dilator muscles in maintaining pharyngeal stability. Electrical stimulation of the genioglossus muscle improves both upper-airway diameter and ameliorates pharyngeal obstruction. The results of phase I and II clinical trials hold promise, but the reported improvements in the apnea-hypopnea index vary between subjects and concerns about long-term safety await long-term studies. The second technology relies on creating an increased expiratory nasal resistance via a bidirectional valve designed to be worn just inside the nostrils. Initial findings of clinical trials suggest reduction in severity of sleep apnea and subjective daytime sleepiness. Considerable heterogeneity in response to the nasal device was noted despite the high adherence rates. It remains unclear which patients will likely benefit a priori from these devices. [ABSTRACT FROM AUTHOR]

To evaluate cardiac output (CO), both invasive and semi-invasive monitors are used in critical care medicine. The pulmonary artery catheter is an invasive tool to assess CO with the major criticism that the level of its invasiveness is not supported by an improvement in patients' outcomes. The interest in a lesser invasive techniques is high. Therefore, alternative techniques have been developed recently, and are used frequently in critical care medicine. Cardiac output can be monitored continuously by different devices that analyze the stroke volume and CO. The purpose of this review is to understand these new technologies and their applications and limitations. [ABSTRACT FROM AUTHOR]

Obstructive sleep apnea (OSA) is a leading public health problem in both developed and developing nations. However, awareness regarding diagnostic options, management, and consequences of untreated OSA remains inadequate in the perioperative period. Adverse surgical outcomes appear to be more frequent in OSA patients. Immediate postoperative complications may be partially attributed to the negative effects of sedative, analgesic, and anesthetic agents that can worsen OSA by decreasing pharyngeal tone and the arousal responses to hypoxia, hypercarbia, and obstruction. Rebound rapid eye movement sleep after anesthesia and the use of opioids may contribute to adverse events in the postoperative period. Even though data to guide clinicians in the perioperative period is scarce, heightened awareness is recommended. [ABSTRACT FROM AUTHOR]

Pneumonia remains the leading cause of death in nursing home residents. The accumulation of dental plaque and colonization of oral surfaces and dentures with respiratory pathogens serves as a reservoir for recurrent lower respiratory tract infections. Control of gingivitis and dental plaques has been effective in reducing the rate of pneumonia but the provision of dental care for institutionalized elderly is inadequate, with treatment often sought only when patients experience pain or denture problems. Direct mechanical cleaning is thwarted by the lack of adequate training of nursing staff and residents' uncooperativeness. Chlorhexidine-based interventions are advocated as alternative methods for managing the oral health of frail older people; however, efficacy is yet to be demonstrated in randomized controlled trials. Development and maintenance of an oral hygiene program is a critical step in the prevention of pneumonia. While resources may be limited in long-term-care facilities, incorporating oral care in daily routine practice helps to reduce systemic diseases and to promote overall quality of life in nursing home residents. [ABSTRACT FROM AUTHOR]

Background: The high efficacy of continuous positive airway pressure (CPAP) in treating obstructive sleep apnea (OSA) is limited by poor compliance often related to pressure intolerance. Mandibular advancement devices (MADs) are proven alternative therapy although not universally effective. A combination of nasal CPAP and MAD may provide another option for CPAP-intolerant patients with incomplete response to MAD. Methods: Ten patients with residual apnea/hypopnea events on MAD who were intolerant to CPAP were recruited prospectively from the sleep clinic. After a washout period of 1 week off MAD, subjects were asked to use an auto-CPAP unit along with their prescribed MAD for three consecutive nights. Oxygen desaturations were obtained from overnight oximetry. Efficacy of the combination therapy was evaluated by the Epworth Sleepiness Scale and Smartcard data recordings. Results: The combination of MAD and nasal CPAP was well tolerated by all participants. Compared to CPAP alone, the optimal CPAP pressure required to eliminate all obstructive events on the combination therapy was reduced from 9.4 ± 2.3 to 7.3 ± 1.4 cm HO ( p = 0.001). The residual apnea hypopnea index on the MAD decreased from 11.2 ± 3.9 to 3.4 ± 1.5 on the combination therapy ( p < 0.001). The number of oxygen desaturations was also less with the combination therapy than with MAD ( p < 0.001). Both the MAD and the combination therapy were effective in reducing daytime sleepiness from 12.7 ± 2.1 at baseline to 9.7 ± 3.1 ( p = 0.04) and 7.5 ± 4.1 ( p = 0.007), respectively. Conclusions: Combination therapy of MAD and nasal CPAP is effective in normalizing respiratory disturbances of sleep apnea in selected OSA patients who are intolerant to CPAP. [ABSTRACT FROM AUTHOR]

We have surveyed the availability of equipment, content of difficult-airway carts (DAC), and training in the use of such equipment in intensive-care units (ICU). We devised a set of proposals regarding what constitutes the ideal DAC. We surveyed 300 ICU in the United States. The survey was conducted to inquire about the presence and content of a DAC. Only 70% of respondents had a DAC in their unit. 82% of units surveyed checked the contents of the cart daily. 80% of directors were aware of its location. 80% of units had an attached list of contents and 51% had an attached algorithm for management of a difficult airway. LMA was present in 80% followed by 35 and 30% for Combitube and pre-assembled needle cricothyroidotomy set. Under non-invasive airway devices, video laryngoscope with 48% was ahead of fibreoptic bronchoscope (38%) and lighted stylet (15%). 80% of units had a CO-detection device immediately available. Limited data are available on the impact of DAC in airway management in the ICU. It is strongly recommended that a DAC be present. What constitutes the ideal contents of a DAC is open to questions. We hope discussion will lead to consensus of what should or should not be included on the cart. [ABSTRACT FROM AUTHOR]

The use of supplemental sodium bicarbonate for the treatment of patients with septic shock and elevated blood lactate levels remains a controversial therapy. We conducted a retrospective study between March 2004 and February 2009 of 36 consecutive patients diagnosed with septic shock who received continuous infusion of bicarbonate therapy. A control group was matched 1:1 for age, site of infection, and predicted mortality by APACHE II. All patients were managed according to standard protocols. The median time until reversal of shock did not achieve statistical significance between the bicarbonate group (44.5 h [95% confidence interval [CI] 34–54] and the control group (55.0 h [95% CI 39–60] ( p = 0.09). The median time to liberation of mechanical ventilation was significantly reduced in the bicarbonate group (10 days [95% CI 5.0–13.0] compared to the control group (14 days [95% CI 9.0–19.0], p = 0.02). The length of intensive care unit (ICU) stay was also shorter in the surviving patients who received bicarbonate compared to controls (median 11.5 days (95% CI 6.0–16.0) vs. 16.0 days (95% CI 13.5–19.0), respectively; p = 0.01). However, there was no difference in 28-day mortality between the two study groups (28%; 95% CI 14–45% vs. 33%; 95% CI 19–51%, respectively; p = 0.79). Infusion of sodium bicarbonate in septic patients with arterial hyperlactatemia may facilitate weaning from mechanical ventilation and reduce length of ICU stay. [ABSTRACT FROM AUTHOR]

Purpose Continuous positive airway pressure (CPAP) is considered the standard therapy for obstructive sleep apnea syndrome. In the absence of standard protocol, CPAP titration may be unsuccessful. The purpose of this study was to test the hypothesis that application of an artificial neural network (ANN) to CPAP titration would achieve an optimal CPAP pressure within a shorter time interval and would lead to a decrease in CPAP titration failure. Methods One hundred fifteen patients were randomized 1:1 to either conventional CPAP titration (n=58) or to an ANN-guided CPAP titration (n=57). Both groups were assessed for time to optimal CPAP pressure, for titration failure, and for CPAP compliance therapy. Results Patients in the ANN-guided CPAP titration arm were able to achieve optimal CPAP at a shorter time interval compared to the conventional group (198.7± 143.8 min versus 284.0±126.5 min) (p<0.001). There was also a lower titration failure in patients randomized to the ANN-guided CPAP titration arm (16%) compared to the conventional arm (36%) (p=0.02). Compliance with treatment did not differ across the two arms. Conclusions The use of ANN for guiding CPAP titration may be superior to the conventional method in maximizing the time to achieve optimal CPAP and in reducing CPAP titration failure. [ABSTRACT FROM AUTHOR]

To investigate the potential role of serum and alveolar soluble triggering receptor expressed on myeloid cells (sTREM-1) as a biological marker of pulmonary aspiration syndromes. Prospective cohort study. University-affiliated intensive care unit. Seventy-five patients with pulmonary aspiration and 13 controls receiving mechanical ventilation. Blood and bronchoalveolar lavage (BAL) fluid samples were collected on enrollment. Soluble TREM-1 levels were measured by an enzyme-linked immunosorbent assay. Thirty-eight of 75 participants had documented BAL culture-positive pulmonary aspiration. While circulating levels of sTREM-1 were comparable between those with aspiration syndromes (19.81 ± 12.09 pg/ml) and controls (15.96 ± 11.16 pg/ml) ( p = 0.27), the alveolar levels of sTREM-1 were higher in patients with culture-positive pulmonary aspiration (344.41 ± 152.82 pg/ml) compared with those culture-negative pulmonary aspiration (142.76 ± 89.88 pg/ml; p < 0.001). A cut-off value of 250 pg/ml for alveolar sTREM-1 achieved a sensitivity of 65.8% (95% CI 48.6–80.4) and a specificity of 91.9% (95% CI 78.1–98.2) with an area under the curve of 0.87 (95% CI 0.78–0.94). Alveolar sTREM-1 levels can be a potential biomarker for distinguishing BAL culture-positive from BAL culture-negative pulmonary aspiration. [ABSTRACT FROM AUTHOR]

Objective: To test the hypothesis that alveolar plasminogen activator inhibitor-1 (PAI-1) can identify patients with witnessed aspiration at risk for progression to acute respiratory distress syndrome (ARDS).Design: Prospective observational study.Setting: Medical intensive care unit in a tertiary care center.Patients: Fifty-one patients with witnessed aspiration who had a PaO2/FIO2<300 for a period no less than 4 h from admission.Interventions: Alveolar fluid sampling was performed within 8 h of intubation via luminal suction of the distal airways using a 13-Fr catheter. Plasma levels were collected simultaneously by venipuncture.Measurements and Results: Alveolar PAI-1 antigen levels were more than five times higher in those who progressed to ARDS than in those with uncomplicated aspiration pneumonitis (2687+/-1498 ng/ml vs. 587+/-535 ng/ml, respectively; p<0.001), while plasma levels of PAI-1 antigen were not significantly different between the two groups. The measured activity of PAI-1 antigen paralleled the levels observed in both media. A cut-off level of alveolar PAI-1 >1518 ng/ml was found to be 82.4% (56.6%-96.0%) sensitive and 97.1% (84.6%-99.5%) specific in predicting progression to ARDS. There was also a significant inverse relationship between elevation of PAI-1 antigen levels and the degree of lung injury as assessed by the days of unassisted ventilation (r2=0.37; p<0.001).Conclusions: Elevation of alveolar PAI-1 antigen levels postaspiration is the consequence of local rather than systemic activation of the fibrinolytic system. Measurement of alveolar PAI-1 antigen levels can be a useful clinical marker in predicting progression to ARDS after gastric aspiration. [ABSTRACT FROM AUTHOR]

Objective: To determine the homeostatic balance of patients with ventilator-associated pneumonia (VAP) with respect to the adequacy of antimicrobial therapy.Design and Setting: Descriptive observational study in a 12-bed medical intensive care unit in a university-affiliated hospital.Patients: Twenty-nine patients with VAP documented by quantitative culture of bronchoalveolar secretions and a control group of eight mechanically ventilated patients.Methods: Serial bronchoalveolar lavage fluid (BALF) samples were assayed for prothrombin activation fragment (F1+2), thrombin-antithrombin (TAT) complex, fibrinolytic activity, urokinase-type plasminogen activator (u-PA), and plasminogen activator inhibitor type 1 (PAI-1) on days 1, 4, and 7 after VAP onset.Results: Pathogens isolated from patients with inadequate empirical antimicrobial coverage included methicillin-resistant Staphylococcus aureus (n=2), Pseudomonas aeruginosa (n=4), and Acinetobacter baumannii (n=1). Compared to those who received adequate antibiotic therapy, TAT, F1+2, and PAI-1 levels increased while u-PA levels remained unchanged. Despite antibiotic adjustment on day 4, TAT levels remained elevated in those who lacked adequate antimicrobial coverage and were significantly correlated with PaO(2)/FIO(2). The procoagulant activity was accompanied by a local depression of fibrinolytic capacity that was attributed mainly to increased BALF PAI-1 levels. Nonsurvivors showed significantly higher levels of TAT and PAI-1 than survivors. No significant correlation between the bacterial burden and the homeostatic derangements was documented.Conclusions: The lung inflammatory response seems to promulgate a local procoagulant activity associated with hypoxemia in those with inadequate antibiotic therapy. The homeostatic derangement seems to be independent of the lung bacterial burden. [ABSTRACT FROM AUTHOR]

Objectives: The purpose of this study was to assess the prevalence and recovery time of swallowing dysfunction after prolonged endotracheal intubation in critically ill elderly patients compared to a younger cohort.Design: This was a prospective, interventional, clinical study set in a medical intensive care unit in a university-affiliated hospital.Subjects: The study involved 42 consecutive elderly patients (>/=65 years old) and 42 controls (<65 years) matched for severity of illness requiring endotracheal intubation for more than 48 h.Interventions: A fiberoptic endoscopic evaluation of swallowing (FEES) was performed within 48 h post-extubation and on days 5, 9, and 14 for those with evidence of aspiration. RESULTS. Swallowing dysfunction was assessed by the detection of test material below the true vocal cords. Aspiration was documented in 52% of the elderly and 36% of the control group (P=0.2). No significant difference in the co-morbidity index and the length of mechanical ventilation was found between aspirators and non-aspirators. None of the control group had swallowing deficits after 2 weeks, while 13% of the elderly participants showed persistent impairment in the swallowing reflex. By multivariate analysis, the preadmission functional status was the only determinant of a slowly resolving swallowing deficit (hazard ratio 1.68; 95% confidence interval 1.26-3.97). No post-extubation aspiration pneumonia was identified in either group.Conclusions: Critically ill elderly patients exhibit delayed resolution of swallowing impairment post extubation. FEES should be considered for those with impaired preadmission functional status. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the predictive ability of three severity of illness scoring systems in elderly patients with severe pneumonia requiring mechanical ventilation compared to a younger age group.Design: Prospective cohort study.Setting: Two university-affiliated tertiary care hospitals.Patients and Participants: One hundred four patients 75 years of age and older and 253 patients younger than 75 years of age enrolled from medical intensive care units.Measurements and Results: Probabilities of hospital death for patients were estimated by the Acute Physiology and Chronic Health Evaluation (APACHE) II, the Mortality Probability Model (MPM) II and the Simplified Acute Physiology Score (SAPS) II. Predicted risks of hospital death were compared with observed outcomes using three methods of assessing the overall goodness of fit. The actual mortality of the elderly group was 54.87 % (95 % confidence interval [CI]: 45.2-64.4 %) compared to 28.9 % (95 % CI, 23.3-34.4 %) in the younger age group. There was a significant difference in the predictive accuracy of the scoring systems as assessed by the c-index, which is equivalent to the area under the receiver operator characteristics (ROC) curve, between the two groups, but not within individual groups. Calibration was insufficient for APACHE II and SAPS II in the elderly cohort as in-hospital mortality was lower than the predicted mortality for both models.Conclusions: Although the three severity of illness scoring systems (APACHE II, MPM II and SAPS II) demonstrated average discrimination when applied to estimate hospital mortality in the elderly patients with severe pneumonia, MPM II had the closest fit to our database. Alternative modeling approaches might be needed to customize the model coefficients to the elderly population for more accurate probabilities or to develop specialized models targeted to the designed population. [ABSTRACT FROM AUTHOR]