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This is a retrospective chart review evaluating the effectiveness of a nurse practitioner–implemented continuous positive airway pressure (CPAP) desensitization protocol on adherence in CPAP-intolerant OSA patients. CPAP adherence (use for ≥ 4 hours/night, ≥ 70% of nights) was calculated after 90 days of CPAP desensitization. The CPAP desensitization protocol resulted in a 1-hour increase in use in one-third of the patients. Only 4 of 22 (18%) patients achieved adequate adherence. Adherence was not associated with demographic, clinical, or polysomnographic variables. A CPAP desensitization protocol for CPAP-intolerant patients can enhance adherence. A larger, multicenter, randomized controlled trial is needed to validate our findings.

RATIONALE AND OBJECTIVE: The safety of intensive blood pressure (BP) targets is controversial for persons with chronic kidney disease (CKD). We studied the effects of hypertension treatment on cerebral perfusion and structure in those with and without CKD. STUDY DESIGN: Neuroimaging substudy of a randomized trial. SETTING & PARTICIPANTS: A subset of participants in the Systolic Blood Pressure Intervention Trial who underwent brain MRI studies. Presence of baseline CKD was assessed by estimated glomerular filtration rate (eGFR) and urine albumin to creatinine ratio (UACR). INTERVENTION: Participants were randomly assigned to intensive (systolic BP 30 mg/g (N=151), the effects of intensive versus standard BP treatment on change in global cerebral blood flow, WMLs and total brain volume were 1.91 ml/100g/min (95% CI −3.01, 6.82), 0.003 cm(3) (asinh transformed, 95% CI −0.13, 0.13), and −7.0 cm(3) (95% CI −13.3, −0.3), respectively. The overall treatment effects on cerebral blood flow and total brain volume were not modified by baseline eGFR or UACR; however the effect on WMLs was attenuated in participants with albuminuria (interaction p-value 0.04). LIMITATIONS: Measurement variability due to multi-site design. CONCLUSIONS: Among hypertensive adults with primarily early kidney disease, intensive versus standard blood pressure treatment did not appear to have a detrimental effect on brain perfusion or structure. The findings support the safety of intensive blood pressure treatment targets on brain health in persons with early kidney disease. FUNDING: The Systolic Blood Pressure Intervention Trial was funded by the National Institutes of Health (including the National Heart, Lung, and Blood Institute, the National Institute of Diabetes and Digestive and Kidney Diseases, the National Institute on Aging, and the National Institute of Neurological Disorders and Stroke), and this substudy was funded by the National Institutes of Diabetes and Digestive and Kidney Diseases. TRIAL REGISTRATION: SPRINT was registered at ClinicalTrials.gov with the study number NCT01206062.

Obstructive sleep apnea (OSA) adversely impacts virtually all organ systems. Neurocognitive consequences include impairments in daytime alertness, attention/vigilance, long-term visual and verbal memory, visuospatial/constructional abilities, and executive function while neuropsychological ones include depression, somatic syndromes, anxiety, and attention deficit/hyperactivity disorder. Cardiovascular consequences of OSA include CHF, systemic hypertension, ischemic heart disease, atrial fibrillation, ventricular arrhythmia, and stroke. Respiratory consequences include poor symptom control in asthma, worse pulmonary function in chronic obstructive pulmonary disease (COPD), increased frequency of exacerbation in both asthma and COPD, increased prevalence and recurrence of pulmonary embolism, and a higher prevalence pulmonary hypertension. Endocrine consequences include diabetes mellitus, metabolic syndrome, and sexual dysfunction in men and women. Gastrointestinal consequences include gastroesophageal reflux disease and nonalcoholic fatty liver disease. Obstetric consequences include pregnancy-related hypertensive disorders and gestational diabetes, as well as maternal cardiovascular, pulmonary, and surgical complications. Perinatal consequences include low birth weight, preterm birth, NICU admission, and hyperbilirubinemia. Perioperative consequences include postoperative ICU transfer, respiratory complications, cardiovascular events, and neurologic complications. Accident-related consequences include motor vehicle crashes and work-related injuries. Oncologic consequences include increased cancer incidence including breast and colorectal cancer. Mortality-related consequences include higher death rates overall and from cardiovascular, noncardiovascular, and COPD-related causes. Nocturnal respiratory dysfunction (i.e., hypoxemia-reoxygenation and hypercapnia), poor sleep quality (i.e., increased arousals, poor sleep efficiency, and altered sleep architecture), and intrathoracic pressure variations result in oxidative stress, inflammation, sympathetic activation, endothelial dysfunction, neurohormonal changes, thrombophilia, and hemodynamic changes, which are the mechanisms for these adverse clinical outcomes.

The 6-minute walk test (6MWT) is not intended to document oxygen (O2) desaturation during exertion but is often used for this purpose. Because of this, it only has modest reproducibility in determining the need for ambulatory O2 therapy in patients with cardiopulmonary disease. The diagnostic and prognostic value of detecting exertional O2 desaturation is still unknown. The aims of this study were to estimate the prevalence of O2 desaturation during a 6MWT based on pulse oximetry measurements at the beginning and end of a 6MWT in a clinical population of patients with suspected cardiopulmonary disease and to determine whether the pulmonary function test (PFT) can predict exercise-induced desaturation during a 6MWT. This retrospective cohort study reviewed the results of the 6MWT and the PFT (i.e., spirometry, lung volumes, and diffusion capacity) of all patients who were evaluated for suspected cardiopulmonary disease at an academic medical center during a 5-year study period. The patients were categorized into three groups based on the change in O2 saturation by pulse oximetry (SpO2) from start to end of the 6MWT: (1) SpO2 decreased by &ge, 3%, (2) SpO2 unchanged (&minus, 2 &le, &Delta, &le, 0%), and (3) SpO2 increased by &ge, 1%. Demographic, anthropometric, and lung function measurements were analyzed to determine which factors predicted O2 desaturation during the 6MWT. Of the 319 patients who underwent the 6MWT and the PFT from November 2005 until December 2010 (mean age = 54 &plusmn, 0.78 years, 63% women, 58% Whites, body mass index = 29.63 &plusmn, 8.10 kg/m2), 113 (35%) had a decreased SpO2, 146 (46%) had no change, and 60 (19%) had an increased SpO2 from the start to end of test. Our bivariate analysis found age, spirometric measures, and diffusion capacity for carbon monoxide (DLCO) had statistically significant inverse associations with the SpO2 change category (p &lt, 0.001). Both a 3% and 4% drop in SpO2 during the 6MWT were statistically significantly associated with an older age, a higher prevalence of obstruction, and reduced forced vital capacity (FVC), forced expiratory volume in one second (FEV1), FEV1/FVC, DLCO and 6-minute walk distance (6MWD). Multivariable logistic regression analyses revealed that only DLCO was a significant independent predictor of the change in SpO2 and a &ge, 4% O2 desaturation during a 6MWT. Receiver operating curve analysis indicates DLCO cut-off of 45% is 82% sensitive and 40% specific in identifying &ge, 4% O2 desaturators, with an area under the curve of 0.788 &plusmn, 0.039 (p &lt, 0.001). The prevalence of a &ge, 3% oxygen desaturation via pulse oximetry during a 6MWT in our clinical population of patients with suspected cardiopulmonary disease was 35%. Although age, spirometric lung volumes, and DLCO had statistically significant unadjusted inverse associations with the change in SpO2 during a 6MWT, the DLCO is the only significant independent predictor of both the magnitude of the change in SpO2 and the occurrence of O2 desaturation of at least 4%, respectively, during the test. Clinical Implications: A DLCO cut-off of 45% may be useful in identifying patients at risk for exertional hypoxemia during a 6MWT.

Purpose of Review This paper aims to critically evaluate recent literature on the epidemiology, pathophysiology, and management of overlap syndrome (OS).

Sleep-related complaints and disturbances are increasingly recognized in the setting of chronic liver disease and have recently been shown to be an important prognostic factor in patients with advanced chronic liver disease. This article reviews the literature surrounding sleep disturbances and disorders in a variety of types of chronic liver disease. This includes the association of sleep disturbances with hepatitis C and antiviral therapy, primary biliary cirrhosis, and Wilson disease as well as the circadian rhythm abnormalities present in cirrhosis and hepatic encephalopathy. The association between chronic liver disease, particularly nonalcoholic fatty liver disease, and sleep-disordered breathing is also reviewed in detail.

Normal aging is accompanied by changes in the sleep quality, quantity, and architecture. Specifically, there appears to be a measurable decrease in the ability of the healthy elderly to initiate and maintain sleep, accompanied by a decrease in the proportion of the deeper, more restorative slow-wave sleep and rapid eye movement sleep. There is epidemiologic evidence that this impaired ability to initiate, maintain, and ultimately achieve good quality, optimal sleep may be a marker of increased mortality and neurocognitive dysfunction. Possible mechanisms related to these age-related changes in sleep include age-related changes in circadian modulation, homeostatic factors, cardiopulmonary function, and endocrine function. This article describes the normal changes in sleep physiology in the elderly.

Obstructive sleep apnea (OSA) has been associated with multiple cardiovascular comorbidities. Despite increased awareness of OSA and its treatments, the management of OSA in the hospital setting remains below expectations. We retrospectively reviewed the demographics, clinical characteristics, and hospital course on 413 consecutive patients with a history of OSA on domiciliary CPAP therapy admitted to the general medical ward and analyzed the prevalence of CPAP use and its effect on length of stay (LOS), 30-day readmission rate, and time-to-readmission in our tertiary care teaching hospital. Of the 413 study participants, 264 (64.0 %) patients were receiving CPAP during their hospital admission. Patients who were receiving CPAP therapy during their hospitalization had a significantly higher body mass index (BMI) (41.4 vs. 36.8 kg/m2, p

Summary Purpose Obesity is characterised by chronic, low-grade systemic inflammation. Elevated FeNO levels reflect airway inflammation in various lung diseases including asthma. Methods This is a cross-sectional analysis of data from NHANES 2007–2010. Participants younger than 20 years old with history of cough/cold symptoms in the past 7 days, smoking, exercise in the previous hour, consumption of nitric oxide rich meats/vegetables, or use of inhaled corticosteroids during the previous 2 days were excluded. BMI (in kg/m 2 ) was divided in to 4 categories: underweight (UW) (0–18.5), Normal (N) (≥18.5 to Results There were a total of 149,629,652 weighted participants: UW (22,235,218), N (45,021,536), OW (5,1670,522) and O (50,199,974); 50.36% were men and 49.63% were women. The mean age increased with BMI category [ p p = 0.0035]. FEV1/FVC (%) decreased with increasing BMI category: UW (80.68) compared to N (78.51), OW (77.67) and O (78.72) [ p = 0.0014]. There is a weak yet statistically significant correlation between FeNO levels and both age, BMI. Multivariate analysis predicting FeNO based on BMI category, adjusting for age, gender, race and airway obstruction found age less than 60 years, male gender, certain races and UW BMI category were associated with statistically significantly lower FeNO levels. Conclusions Older age and male gender are associated with increased FeNO levels. Controlling for age, gender, and race, obese individuals have a statistically significantly higher FENO than underweight individuals.

The International Classification of Sleep Disorders Third Edition (ICSD-3) lists five major types of sleep-related breathing disorders (SRBDs), including obstructive sleep apnea (OSA) disorders, central sleep apnea (CSA) syndromes, sleep-related hypoventilation (SRHV) disorders, sleep-related hypoxemia (SRHO) disorders, and isolated symptoms and normal variants. Positive airway pressure (PAP) treatment-emergent CSA, also known as complex sleep apnea, has been classified under CSA syndromes while mixed sleep apnea (both obstructive and central apneas occurring during the diagnostic study) has not yet been listed in the ICSD-3. Although excessive daytime sleepiness is a well-known consequence of SRBDs, insomnia occurs in 40–60 % of patients with OSA syndrome. Although there are no population-based estimates of the prevalence of the different subtypes of SRBDs, the vast majority (>90 %) of cases seen in clinical practice are due to OSA syndrome. Although habitual snoring and catathrenia (sleep groaning) can be disruptive to other household members’ sleep, these isolated symptoms, in the absence of neurocognitive symptoms and polysomnographically diagnosed sleep apnea, are not associated with adverse cardiovascular outcomes.

Endobronchial leiomyomas are rare benign tumors of the lung, arising from the smooth muscle of the bronchial tree. Symptomatology is based on the degree of endoluminal bronchial obstruction, and surgical resection has generally been the mainstay of treatment. We describe a mechanically ventilated patient with recurrent atelectasis and a postobstructive pneumonia caused by an occlusive endobronchial leiomyoma who was successfully weaned off the ventilator after treatment with argon plasma coagulation delivered via flexible bronchoscopy. We also briefly review the literature.

Pulmonary hypertension can occur from obstruction of the distal pulmonary arteries by thrombus, ova and parasites, and foreign material. We report a 62-year-old patient who had fatal pulmonary hypertension from an 8-cm fragment of a totally implantable venous access device (TIVAD) retained in the pulmonary artery. Despite long-term therapeutic anticoagulation, pulmonary angiography showed chronic occlusion of the posterior branch of the superior right pulmonary artery with paucity of distal vasculature consistent with an old right upper lobe pulmonary embolus. Retrieval of the fragment was attempted via pulmonary artery catheterization techniques but was unsuccessful. In conclusion, progressive pulmonary hypertension may result from retention of a TIVAD fragment in a central pulmonary artery despite therapeutic anticoagulation. Worsening pulmonary hypertension may have been due to partial obstruction of the main pulmonary arteries, resulting in recurrent thromboembolism or in situ thrombosis, and remodeling of small distal pulmonary arteries.

We describe a patient with antiphospholipid antibody syndrome (APS) who died because of relentless inferior vena cava (IVC) tumor thrombosis due to an unsuspected leiomyosarcoma. Laboratory confirmation for APS was provided by functional identification of a lupus anticoagulant and anticardiolipin IgG and anti-beta2-glycoprotein I IgM antibodies. Although sensitive for detecting vascular obstruction, radiocontrast venography and magnetic resonance imaging and angiography detected the IVC thrombosis but failed to distinguish its malignant nature. Concomitant refractory thrombocytopenia prevented further invasive diagnostic and therapeutic maneuvers for progressive, severe IVC thrombosis unresponsive to aggressive treatment of APS. Deep venous thrombosis refractory to anticoagulant and immunomodulatory therapies in a patient with APS may be due to a concomitant underlying malignancy, such as a leiomyosarcoma, causing vascular obstruction.

To our knowledge, we describe the first reported case of paradoxical embolization via a patent foramen ovale (PFO) in an adult with moderately severe cystic fibrosis (CF) and advanced lung disease. Fluctuating neurologic symptoms and signs suggestive of cerebrovascular disease in an adult patient with advanced CF may be due to paradoxical embolization via a PFO. The possibility of a PFO should be considered before placement of a totally implantable venous access device to avert unnecessary risk of stroke in CF patients. Further study is needed to determine whether the use of a totally implantable venous access device increases the risk of paradoxical embolization in adult CF patients with a PFO.

Study objectives This study reports histopathologic findings in a group of emphysema patients who underwent thoracoscopic lung volume reduction surgery (75) or sternotomy (five) with the purpose to induce functional improvement and relief of dyspnea. Immediate outcome and complications were correlated to histologic patterns. Design Histopathologic material obtained in lung volume reduction surgery in 80 consecutive patients was analyzed. Thirty patients who had other histopathologic diagnoses in addition to emphysema were grouped and compared with 50 patients found to have emphysema exclusively. Postoperative outcome and preoperative lung function variables were compared. Measurements and results All patients had severe obstructive lung disease and significant air trapping preoperatively documented by pulmonary function testing. All had severe exertional dyspnea. All had chest radiographs, CT, and nuclear medicine lung scans consistent only with emphysema. All portions of resected lung tissue were weighed, lung volume was estimated, and routine histopathologic studies were made. Thirty patients (37.5%) had unsuspected findings such as interstitial fibrosis, noncaseating granulomatosis, chronic inflammation, and unsuspected neoplasia (three carcinomas, one carcinoid). Retrospective review of imaging studies in these patients failed to show infiltrative processes. The average lung weight resected in this group was significantly heavier (65±18 g) compared with the other group (56±13 g), although both had the same estimated lung volume. Average number of days requiring chest tubes and length of hospitalization was also significantly higher (12.8±19 vs 6.4±5 days with chest tubes and 17.4±22 vs 8.5±6 days of hospitalization, respectively). None of the preoperative pulmonary function tests variables were different between the two groups. Serious postoperative complications were more frequent in these patients compared with those who showed only emphysema. Conclusions A significant portion of patients diagnosed as having severe emphysema will have other unsuspected histologic findings. When subjected to lung volume reduction surgery, this subgroup will have more serious complications and longer periods of air leaks, requiring longer hospitalization time. Retrospective review of imaging studies and preoperative pulmonary function tests used to select patients for lung volume reduction failed to identify this subgroup.

Percutaneous insertion of permanent pacemaker leads through the subclavian vein is an alternative to the cephalic vein approach. A rare occurrence and successful conservative management of extensive pneumomediastinum and subcutaneous emphysema without concomitant pneumothorax resulting from permanent transvenous pacemaker insertion in an 80-year-old man with syncope and arrhythmia is reported.

The value of adjusting the diffusing capacity for the lung volume has been demonstrated in a large number of patients with other lung diseases but has not been validated in patients with cystic fibrosis (CF). Pulmonary function test results on a cohort of 52 adult CF patients were analyzed to determine whether the diffusing capacity of carbon monoxide by single breath method (DLCO(SB)) when adjusted for alveolar volume (V(A)%), correlated with the severity of pulmonary dysfunction. The DLCO(SB) remained within the reference range except in those with severe lung impairment (61.88 +/- 15.48%). DLCO(SB) has a significant (P < 0.05) positive correlation (0.70, 0.67, 048, 0.69 and 0.31, respectively) with measures of airflow limitation (FVC%, FEV1%, FEV1/FVC%, MVV%, and sGaw) and negative correlation (-0.36 and -0.21, respectively) with measures of air trapping (RV% and RV/TLC%). DLCO(SB)/V(A) remained above 100% of predicted despite worsening lung disease and did not correlate with other measures of lung function. On the other hand, the DLCO(SB) and DLCO(SB)/V(A), when adjusted for V(A)%, decreased and were significantly correlated with worsening airflow limitation and, to a lesser extent, air trapping. The relatively preserved adjusted DLCO(SB) and DLCO(SB)/V(A) values in CF patients up until late in its course may be explained the predominant airway involvement, minimal loss of alveolar-capillary units, and enhanced V/Q relationship due to claustration in CF.