Positive Airway Pressure Devices Research Articles

Nonclinical Bench Performance Testing of a Very Low-Cost Nonelectric Bubble Continuous Positive Airway Pressure (bCPAP) and Blenders Device Designed for Newborn Respiratory Support.

PurposeBubble continuous positive airway pressure (bCPAP) is often used to treat respiratory distress experienced by some 15 million preterm infants born globally every year. In low- and middle-income countries, improvised bCPAP devices are used, often without a blender that protects the infant from the sequelae of excessive oxygen exposure.Materials and MethodsThe aim of this bench testing was to assess the mechanical safety and performance of the PATH bCPAP and blenders device, which provides a stable and reliable source of pressurized blended gas without the requirement for a source of compressed medical air or electricity. The device includes two fixed ratio blenders: a “low” blend that provides 37% oxygen and a “high” blend that provides 60% oxygen. We performed bench testing to characterize the performance of the bCPAP and blenders, including respiratory circuit verification, blender verification, conditioned humidity testing, and sound measurement.ResultsTest results for all performance variables met the acceptance criteria of our product requirement specification. The device provides a fixed ratio of air and oxygen that is consistent over the entire range of clinically relevant pressures (4 to 8 cmH2O) and remains consistent despite changes in flow (2 to 7 liters per minute). The blend is stable within ± 5% of the blenders’ nominal blend ratio when used with a 100% oxygen source, irrespective of the flow and pressure from the oxygen source or the flow and pressure of the blended gas delivered to the neonate. Sound and humidity test results were within specifications.ConclusionThis very low-cost nonelectric bCPAP and blenders device is optimally designed to deliver a stable and reliable source of pressurized blended gas.

0789 Mask Magnets May Interact with Pacemakers and Implantable Cardioverter-Defibrillators

Abstract Introduction Placing a magnet over a Permanent Pacemaker (PPM) or Implanted Cardioverter-Defibrillator (ICD) may cause the device to pace asynchronously or inhibit tachyarrhythmia detection, respectively, potentially preventing delivery of electrical shocks. Manufacturers for masks used with positive airway pressure devices have started using magnets in place of more traditional headgear clips to connect the headgear to mask. Mask manufactures do not list presence of a PPM/ICD as a contraindication to use of a mask with magnet but do recommend keeping the mask some distance away from PPM/ICD. A published case series describes two patients with magnet response events captured during PPM/ICD interrogation that correlated with nightly use of CPAP. The authors were able to replicate the response by placing the mask with magnet directly over the patient’s pulse generate site. Although we advise all patients with implanted device to avoid use of masks with magnets, select patients refuse to stop using mask with magnets regardless of our policy. We, therefore, started offering these patients referral for PPM/ICD interrogation to evaluate for an interaction between mask with magnet and PPM/ICD as next best alternative. Methods We retrospectively reviewed all patients (n=10) referred for routine PPM/ICD interrogation to test whether the mask with magnet interacted with PPM/ICD when mask on face as during normal use (i.e., simulated normal use) or magnetic area of mask placed directly over the PPM/ICD (i.e., direct contact). Results Although no interaction was detected in any patient (n=10) with simulated normal use (0 %), one interaction was documented with direct contact (10 %). Conclusion Although simulated normal use of masks with magnets did not demonstrate any interactions, it is concerning that one patient (10 % of patients) demonstrated an interaction with direct contact of magnetic area of mask over the PPM/ICD. It is not uncommon for patients to remove a mask during the night while sleeping. This preliminary data along with the published case series calls for further research and increased awareness of this potential interaction for both sleep and cardiac health care providers. Support (If Any) None

0823 ACDF - A hidden etiology of OSA

Abstract Introduction OSA is characterized by recurrent episodes of upper airway collapse and obstruction during sleep, leading to oxygen desaturations. Risk factors include obesity, age, sex, family history, craniofacial abnormalities, stroke, diabetes, polycystic ovarian syndrome. This case illustrates symptomatic and clinically proven worsening of OSA after anterior cervical discectomy and fusion (ACDF), which can lead to narrowing of the airspace and dysfunction of the pharyngeal plexus leading to upper airway collapse. Report of Cases: A 49-year-old female with cervical myelopathy was evaluated in the sleep clinic for snoring, witnessed apnea, and daytime somnolence. Her Epworth score was 11, and Mallampati score was 4, suggestive of underlying sleep-disordered breathing (SDB). A home diagnostic sleep test revealed mild OSA with AHI of 6.8/hr and was started on an Auto Continuous Positive Airway Pressure (APAP) device. She then reported worsening of her cervical pain leading to decreased use of APAP and total sleep time and underwent ACDF approximately 6 months after her diagnosis of OSA was made. Post-surgery she reported mild dysphagia, frequent nighttime awakening due to a choking sensation, and an increase in snoring. Following hospital discharge, the patient was re-evaluated in the sleep clinic for these complaints. Upon review, her BMI had decreased to 33.99 kg/m2, from 37.35 kg/m2, and the only medication change was the addition of hydrocodone-acetaminophen 5-325, 1-2 times daily as needed for pain. A repeat diagnostic home sleep study showed progression of OSA to moderate severity with an AHI of 24.5/hr, with no evidence of central sleep apnea or hypoventilation. Therefore, it was unlikely that the worsening of AHI was due to opioids. Thus, it was concluded that ACDF most likely led to the worsening of OSA. Conclusion Although there is no strong association in medical or sleep literature, this case demonstrates a strong association between ACDF and OSA. This highlights the importance of a timely diagnosis of new-onset or reassessment for worsening OSA in patients post-ACDF to improve sleep quality and prevent morbidity. Support (If Any)

0787 Healthcare Utilization in Initiation of Oral Appliance vs Positive Airway Pressure Therapy for Sleep Apnea

IntroductionThe COVID-19 pandemic and related supply chain issues have created shortages in integral components of Positive Airway Pressure (PAP) devices, the gold standard treatment for sleep apnea. Concurrently, patients have delayed care and are returning in increasing numbers. With these overlapping pressures, alternative treatments are needed. Custom-fabricated Oral Appliances (OA) are uniquely poised as a solution. However, it is unknown if initiation and treatment cost and healthcare utilization are similar to PAP or will create further disruptions at scale.MethodsPatients who initiated PAP or OA therapy 2018-2020 were included. Matched visits 2017-2021 were referenced. Patients with multiple treatment initiations were excluded. Healthcare utilization quantified number visits, stratified by provider type (Physician, Physician Assistant (PA), American Board of Dental Sleep Medicine (ABDSM) Accredited Dentist, or Registered Polysomnographic Technologist (RPSGT)). Contractual amounts for CPT codes were averaged to estimate cost.Results5172 patients, 374 received OA (7.2%). Prior to initiation, OA therapy utilized more visits on average than PAP (4.5±1.7(±SD) vs 3.5±1.9, p<0.0001). Following initiation, OA therapy utilized fewer visits than PAP (4.1±3.9 vs 5.5±4.6, p<0.0001). Specialized provider visits, i.e. dentist for OA, were lower compared to RPSGT for PAP therapy, both before and after initiation (1.4±0.8 vs 2.0±1.4 before, 1.9±1.2 vs 2.6±1.8 after, both p<0.0001). Further, prior to initiation, Physician and PA utilization was similar between OA and PAP therapies (1.4±0.8 vs 1.5±1.0 Physician, 1.1±0.8 vs 1.2±0.8 PA, both p>0.057). However, following initiation, OA therapy utilized fewer Physician visits than PAP (1.7±1.1 vs 2.1±1.7, p<0.0001) but similar PA visits (1.9±1.5 vs 2.1±1.4, p>0.5). Together, with OA dental visits estimated to be the least expensive associated visit, this analysis estimates that the provider cost of initiation of OA therapy is lower than that of PAP.ConclusionOverall, OA therapy requires less healthcare utilization, especially of providers with highest reimbursement rates. While OA requires more initial appointments, PAP therapy requires more follow up visits with specialized providers and physicians, thereby increasing cost for patients. Additional cost burden of these visits could impact patient willingness to initiate treatment. This analysis provides supportive evidence for OA as an alternative to PAP with lower treatment cost and healthcare utilization, which may provide an advantage for the already over-burdened healthcare system.Support (If Any)

0778 Characterizing Women with Obstructive Sleep Apnea from Real World Data

Abstract Introduction Real-world evidence focused on women with obstructive sleep apnea (OSA) is lacking. This retrospective study aimed to characterize and evaluate the impact of age on female patients with OSA and their journey through OSA diagnosis and treatment. Methods De-identified US administrative claims data for patients with OSA who had a claim for a sleep test were used for this analysis. Age and insurance coverage were characterized at the time of the first sleep test. Comorbidity status was evaluated in the year prior to the sleep test by assessing ICD-9/10 codes associated with healthcare encounters. This protocol was submitted to an Institutional Review Board and was determined to be exempt from oversight. Results The study included 883,902 female OSA patients; mean age of 51.7 years; and 64.9% commercial, 24.7% Medicaid, and 10.3% Medicare Advantage insurance coverage. The most prevalent comorbidities were hypertension (54.9%), hyperlipidemia (46.5%), GERD (31.5%), type 2 diabetes (25.1%), depression (23.2%), and asthma (22.0%). When stratifying by age, the prevalence of all comorbidities increased with age except for affective disorders. Depression and anxiety decreased with age. In terms of the type of sleep test used to diagnose OSA, 58.8% had an in-lab polysomnography (PSG), 38.9% had a home sleep test (HST), and 2.3% had both a PSG and HST. About half (56.6%) of patients received a positive airway pressure (PAP) device in the year after being diagnosed. When stratifying the results by age, in-lab PSG testing was more prevalent in those over 65, while the percentage of those receiving a PAP device increased then slightly decreased with age (18-44y: 47.6%, 45-54y: 58.1%, 55-64y: 62.1%, 65-69y: 61.1%, &amp;gt;70y: 58.8%). Conclusion This retrospective study characterized the start of the women’s journey with OSA; describing the rates of sleep testing and PAP treatment from a sample of real-world data. These results begin to build an understanding of these patients and their journey to treatment, helping to raise awareness of undiagnosed OSA in women. Further research should be conducted to identify potential real-world impact of adherence to PAP on health outcomes. Support (If Any) ResMed

Adherence Index: sleep depth and nocturnal hypoventilation predict long-term adherence with positive airway pressure therapy in severe obstructive sleep apnea.

Treatment of obstructive sleep apnea with positive airway pressure (PAP) devices is limited by poor long-term adherence. Early identification of individual patients' probability of long-term PAP adherence would help in their management. We determined whether conventional polysomnogram (PSG) scoring and measures of sleep depth based on the odds ratio product would predict adherence with PAP therapy 12 months after it was started. Patients with obstructive sleep apnea referred to an academic sleep center had split-night PSG, arterial blood gases, and a sleep questionnaire. Multiple linear regression analysis of conventional PSG scoring and the odds ratio product both during diagnostic PSG and PAP titration provided an "Adherence Index," which was correlated with PAP use 12 months later. Patients with obstructive sleep apnea (n = 236, apnea-hypopnea index 72.2 ± 34.1 events/h) were prescribed PAP therapy (82% received continuous PAP, 18% received bilevel PAP). Each patient's adherence with PAP therapy 12 months later was categorized as "never used," "quit using," "poor adherence," and "good adherence." PSG measures that were most strongly correlated with PAP adherence were apnea-hypopnea index and odds ratio product during nonrapid eye movement sleep; the additional contribution of nocturnal hypoxemia to this correlation was confined to those with chronic hypoventilation treated with bilevel PAP. The Adherence Index derived from these measures, during both diagnostic PSG and PAP titration, was strongly correlated with PAP adherence 12 months later. Long-term adherence with PAP therapy can be predicted from diagnostic PSG in patients with severe obstructive sleep apnea, which may facilitate a precision-based approach to PAP management. Younes MK, Beaudin AE, Raneri JK, Gerardy BJ, Hanly PJ. Adherence Index: sleep depth and nocturnal hypoventilation predict long-term adherence with positive airway pressure therapy in severe obstructive sleep apnea. J Clin Sleep Med. 2022:18(8):1933-1944.

The impact of different CPAP delivery approaches on nightly adherence and discontinuation rate in patients with obstructive sleep apnea.

The impact of direct mail order sales of positive airway pressure (PAP) devices, accentuated by the coronavirus disease 2019 (COVID-19) pandemic, on PAP adherence in patients with obstructive sleep apnea remains unclear. In this study we compared the impact of different modes of continuous positive airway pressure delivery on adherence and daytime symptoms. We hypothesized that adherence would not be affected by remote PAP setup, aided by telehealth technology. Three groups were studied: 1) standard group PAP setup (3-4 people); 2) direct home shipment of PAP, followed by telehealth interactions; 3) direct home shipment of PAP, during the COVID-19 pandemic where delivery choice was removed. Demographics, sleepiness, PAP data, and insurance information were also compared. A total of 666 patients were studied in 3 groups. 1) Standard group PAP setup had 225 patients and adherence with PAP (% of nights used more than 4 hours) was 65.3 ± 2.1%. 2) Direct home shipment of PAP group had 231 patients, and adherence was 54.2 ± 2.4%. 3) Direct mailed PAP units during the COVID-19 pandemic group had 210 patients, and adherence was 55.9 ± 2.5%. Adherence was lower in both groups receiving home shipments compared to those in groups in-center (analysis of variance, Tukey, P = .002). Discontinuation of PAP was less in the in-center group setup patients (χ2 = 10.938 P ≤ .001). Patients receiving direct home PAP shipments had lower adherence and were more likely to discontinue PAP compared to standard in-person setup. Stanchina M, Lincoln J, Prenda S, etal. The impact of different CPAP delivery approaches on nightly adherence and discontinuation rate in patients with obstructive sleep apnea. J Clin Sleep Med. 2022;18(8):2023-2027.

Patient-reported outcome measures following maxillomandibular advancement surgery in patients with obstructive sleep apnoea syndrome

Maxillomandibular advancement (MMA) is an effective treatment for obstructive sleep apnoea syndrome (OSAS) that is refractory to conventional treatment. However, it is a highly invasive procedure with several recognised side effects, and we know of few data on its effect on important patient-reported outcome measures (PROMS). Here we describe a case series of patients selected for MMA through our joint respiratory/maxillofacial surgery clinic, detailing the effect of MMA on objective physiological measurements and important PROMS. Patients with confirmed moderate/severe symptomatic OSAS who could not tolerate continuous positive airway pressure (CPAP) or mandibular advancement devices (MAD) were assessed in the clinic for consideration of MMA. Preoperative and postoperative airway measurements, apnoea/hypopnoea index (AHI), Epworth sleepiness scale (ESS) score, and quality of life (10-point Likert scale), were recorded. A customised questionnaire was administered postoperatively to assess selected psychosocial and functional domains (sleep quality, energy levels, appearance, ability to perform daily activities, and mood) and patient satisfaction using five-point Likert scales. Over an 18 month period, 39 patients were referred for consideration of MMA. Ten patients (7 men and 3 women, mean age 49.9, mean BMI 27.5) underwent surgery, which resulted in significant improvements in ESS, quality of life, AHI, and airway diameters. All patients reported improvements in all psychosocial/functional domains except appearance, in which five reported no change or worsened appearance. All subjects felt that MMA provided better symptom control than CPAP. The most commonly reported side effects were facial/lip numbness (9/10) and affected bite (6/10). MMA resulted in significant improvements in ESS, quality of life, and a range of PROMS, with a high level of patient satisfaction.

Conceptual model of low-cost improvised bubble continuous positive airway pressure device for adults and its potential use in the COVID-19 pandemic.

Low-cost improvised continuous positive airway pressure (CPAP) device is safe and efficacious in neonatal respiratory distress. There is a great necessity for similar device in adults, and this has been especially made apparent by the recent Coronavirus Disease 2019 (COVID-19) pandemic, which is unmasking the deficiencies of healthcare system in several low-resource countries. We propose a simplified and inexpensive model of improvised CPAP in adults using locally available resources including aquarium air pumps and a novel pressure release mechanism. Although the safety and efficacy of improvised CPAP in adults are not established, the conceptual model we propose has the potential to serve as a lifesaving technology in many low-resource settings during this ongoing pandemic and thus calls for expedited research.

Telemedicine in sleep-related breathing disorders and treatment with positive airway pressure devices. Learnings from SARS-CoV-2 pandemic times.

The healthcare system currently faces new challenges, which are to be addressed by finding efficient alternatives. Such factors as the growth of world population, the increase in longevity, and the fact that some diseases which used to be deadly diseases have turned into chronic pathologies, cause the number of people in need for continuous medical care to rise. This results in a healthcare system crisis, which searches for solutions as telemedicine to address the needs of patients and control excessive medical spending. Telemedicine means remote medical assistance delivered by means of technological resources, which streamline the provision of medical care, thus increasing patient’s access to healthcare and saving time and costs. As regards respiratory diseases, telemedicine is a tool that may provide for proper prevention, diagnosis, therapeutic education, monitoring of observance, and therapeutic efficacy, as well as for the early detection of exacerbations. Patients suffering from sleep-related respiratory disorders in need for positive airway pressure devices may be benefited by telemedicine to enhance positive pressure adherence and follow-up to treat their pathologies, thus providing for the delivery of remote care and follow-up, reducing costs, and increasing the chances of receiving attention from specialists in patients who live a long distance from such medical facilities. However, it is a challenging task to find a balance in the doctor-patient virtual relationship.

Adherence to Positive Airway Pressure therapy as Severity of Adult Obstructive Sleep Apnea

Background and Objectives The aim of this study was to compare adherence to positive airway pressure (PAP) therapy in patients with obstructive sleep apnea (OSA) of different severity.Subjects and Method We conducted a retrospective study including 270 adult OSA patients who used a PAP device for at least 3 months. We assessed the percentage of days on which the device was used, the percentage of days on which the device was used for ≥4 h, and the average duration of PAP device usage at 12 weeks of PAP therapy. We also evaluated adequate adherence to PAP therapy using a PAP device for ≥4 h/day and during ≥70% of nights.Results The percentage of days on which a PAP device used did not differ significantly according to OSA severity (median [Q1-Q3]; mild: 91.40% [81.25%-97.65%], moderate: 94.50% [86.90%-100%], severe: 95.90% [88.10%-100%], p=0.268). We also found that the percentage of days on which a PAP device was used during sleep for ≥4 h was not significantly different in patients with different OSA severity (median [Q1-Q3], mild: 76.20% [69.70%-89.90%], moderate: 89.30% [67.65%-95.70%], severe: 85.70% [75.85%-95.45%], p=0.097). The percentage of patients with adequate PAP adherence did not differ significantly according to OSA severity (mild: 74.2%, moderate: 72.1%, severe: 83.0%, p=0.084). Moreover, the mean duration (minutes) of PAP device usage during sleep did not differ significantly according to OSA severity in the mild, moderate, and severe OSA groups (mean±standard deviation, mild: 348.03± 47.78 min, moderate: 358.58±85.22 min, severe: 363.79±57.21 min, p=0.440).Conclusion Adherence to PAP therapy did not differ significantly according to OSA severity. Therefore, it is necessary to continuously expand and maintain the insurance for health promotion in OSA patient in South Korea.

Continuous Positive Airway Pressure vs Mandibular Advancement Devices in the Treatment of Obstructive Sleep Apnea: An Updated Systematic Review and Meta-Analysis.

Introduction: Obstructive sleep apnea (OSA) is the most common sleep-related breathing disorder which has various treatment options, however, continuous positive airway pressure (CPAP) remains the gold standard. The aim of this meta-analysis is to compare the current first-line treatment of OSA, i.e., the continuous positive airway pressure (CPAP) with mandibular advancement devices (MADs) in mild to severe OSA.Objective: This meta-analysis is a comparison of the efficacy of continuous positive airway pressure vs mandibular advancement devices in patients with mild to severe obstructive sleep apnea. The primary objective of the meta-analysis is to compare the efficacy of CPAP vs MADs in the treatment of OSA. This meta-analysis includes randomized control and cross-over studies that compare the efficacy of CPAP and MAD and outcomes are reported in terms of apnea-hypopnea index (AHI), lowest oxygen saturation, and Epworth sleepiness scale both pre- and post-treatment.Data sources and study selection: A PubMed and Cochrane database search was conducted in May 2021 and study bibliographies were reviewed. Randomized clinical trials comparing the effect of CPAP and MAD on AHI, lowest oxygen saturation, and ESS in patients with obstructive sleep apnea were selected. Of the 436 studies initially identified, eight were selected for analysis after screening. The quantitative measures used for comparing the efficacy of CPAP and MAD were post-treatment apnea-hypopnea index (AHI), lowest oxygen saturation, and post-treatment Epworth score scale (ESS).Data extraction and synthesis: A network of meta-analyses was performed using RevMan (Copenhagen, Denmark: Nordic Cochrane Center) where multivariate random-effects models were used to generate pooled estimates. Data were analyzed using generic inverse variance method and P < 0.05 is regarded as statistically significant. Combined summary statistics of standardized (STD) paired difference in mean for individual studies and combined studies was calculated. A chi-square-based test of homogeneity was performed and the inconsistency index (I2) statistic was determined.Results: Compared the AHI, lowest oxygen saturation, and ESS from baseline to follow-up pre- and post-treatment in both CPAP and MAD groups; after the database search 436 records were identified, eight studies were included in the RCT, and three were RCT crossover studies. The duration of treatment varies in each group. AHI, ESS, and lowest oxygen saturation are calculated pre- and post-treatment. Compared with MAD, CPAP was associated with decrease in AHI with a mean difference of -5.83 (95% CI, -8.85, -2.81, P < 0.01). The lowest oxygen saturation was also decreased in CPAP group compared to MAD group with a mean difference of 0.72 (95% CI, 0.51, 0.94, P < 0.01). However, there was no statistically significant difference in ESS between CPAP and MAD group with a mean difference of 0.23 (95% CI, -0.24, 0.70, P = 0.34). The meta-analysis states that among patients with obstructive sleep apnea, both CPAP and MADs are effective in reducing the AHI and lowest oxygen saturation, however, no significant difference was found in ESS pre- and post-treatment.Conclusions: CPAP still remains the gold standard for the treatment of OSA and should continue to be recommended as a treatment for OSA. MAD can be used as adjunctive treatment or as a treatment for those who cannot readily access or do not prefer CPAP.

Outcomes of Pediatric Titration Sleep Studies Following Empirical Use of Positive Airway Pressure and the Effect on Adherence to Therapy.

Obstructive sleep apnea (OSA) is diagnosed through polysomnography (PSG) testing and commonly treated with positive airway pressure (PAP). The initial recommended treatment for pediatric OSA is adenotonsillectomy, but when this is contraindicated or ineffective, PAP is the next option. Children followed in our pediatric sleep disorders center who are diagnosed with OSA and meet criteria for therapy are empirically prescribed a PAP device, usually auto-titrating PAP (APAP), to avoid delays in therapy. Titration PSG is performed later to assess adequacy of settings. The aims of this study were to determine how often PSG titration results in changes to empirically prescribed PAP and to assess adherence to therapy before and after PSG titration. A retrospective medical records review was completed for children diagnosed with OSA, prescribed PAP, and had a titration PSG within a 5-y consecutive period of 2008-2012. Demographic data, type of device, pressure settings, and adherence downloads were reviewed. Adherence was assessed before and after titration overall and compared for those who did and did not have therapy changes following titration. The study included 121 participants. Median age at the time of the diagnostic PSG was 11 (interquartile range [IQR] 8-14) y. Most (106, 88%) were initially prescribed APAP. Median length of time between initial and follow-up PSG was 6.4 (IQR 4.4-10.1) months. The majority (94, 78%) had therapy changes following titration. Overall, adherence percentage > 4 h per night was not significantly increased post titration (P = .47). There were no statistically significant differences in adherence between those who had therapy changes and those who did not (P = .26). Titration studies resulted in therapy modifications for most children. Adherence was not increased following the titration PSG. Changes in therapy did not result in increased adherence. Titration PSGs may optimize empirically prescribed settings.

Elevated serum matrix metalloproteinase-2 levels in heart failure patients with reduced ejection fraction and Cheyne-Stokes respiration.

Cheyne-Stokes respiration (CSR), a kind of central sleep apnea, is referred to as a poor prognostic factor in heart failure patients with reduced ejection fraction (HFrEF). Matrix metalloproteinase (MMP) and B-type natriuretic peptide (BNP) play important roles in HFrEF patients and are markers of poor prognosis. However, there is no literature mentioning the changes in MMP and BNP in HFrEF patients with CSR. From June 2018 to June 2019, 41 adult patients with stable heart failure and left ventricular ejection fraction < 50% were enrolled from the cardiology clinic. After history-taking and medication review to exclude possible central nervous system- or medication-related central sleep apnea, an overnight polysomnography study was performed, and CSR was identified. The morning serum MMP-2, MMP-9, and BNP levels were determined using enzyme-linked immunosorbent assay and fluorescence immunoassay techniques. A positive airway pressure device was applied to 7 patients for 3 months. The serum MMP-2 and BNP levels were significantly higher in HFrEF patients with CSR than in patients without CSR. In addition, elevated serum MMP-2 levels correlated well with the severity of sleep apnea and intermittent hypoxia, which were represented as the apnea-hypopnea index and the oxygen desaturation index. No positive correlation was found between those markers and left ventricular ejection fraction. Finally, the treatment of sleep apnea with continuous positive airway pressure for 3 months tended to reduce the elevated serum MMP-2 levels. Higher serum MMP-2 and BNP levels were found in HFrEF patients with CSR. Elevated MMP-2 levels were correlated with the severity of sleep apnea and intermittent hypoxia. Chuang L-P, Pang J-HS, Lin S-W, etal. Elevated serum matrix metalloproteinase-2 levels in heart failure patients with reduced ejection fraction and Cheyne-Stokes respiration. J Clin Sleep Med. 2022;18(5):1365-1373.

Assessment of Patient Journey Metrics for Users of a Digital Obstructive Sleep Apnea Program: Single-Arm Feasibility Pilot Study.

BackgroundDespite the importance of diagnosis and treatment, obstructive sleep apnea (OSA) remains a vastly underdiagnosed condition; this is partially due to current OSA identification methods and a complex and fragmented diagnostic pathway.ObjectiveThis prospective, single-arm, multistate feasibility pilot study aimed to understand the journey in a nonreferred sample of participants through the fully remote OSA screening and diagnostic and treatment pathway, using the Primasun Sleep Apnea Program (formally, Verily Sleep Apnea Program).MethodsParticipants were recruited online from North Carolina and Texas to participate in the study entirely virtually. Eligible participants were invited to schedule a video telemedicine appointment with a board-certified sleep physician who could order a home sleep apnea test (HSAT) to be delivered to the participant's home. The results were interpreted by the sleep physician and communicated to the participant during a second video telemedicine appointment. The participants who were diagnosed with OSA during the study and prescribed a positive airway pressure (PAP) device were instructed to download an app that provides educational and support-related content and access to personalized coaching support during the study’s 90-day PAP usage period. Surveys were deployed throughout the study to assess baseline characteristics, prior knowledge of sleep apnea, and satisfaction with the program.ResultsFor the 157 individuals who were ordered an HSAT, it took a mean of 7.4 (SD 2.6) days and median 7.1 days (IQR 2.0) to receive their HSAT after they completed their first televisit appointment. For the 114 individuals who were diagnosed with OSA, it took a mean of 13.9 (SD 9.6) days and median 11.7 days (IQR 10.1) from receiving their HSAT to being diagnosed with OSA during their follow-up televisit appointment. Overall, the mean and median time from the first televisit appointment to receiving an OSA diagnosis was 21.4 (SD 9.6) days and 18.9 days (IQR 9.2), respectively. For those who were prescribed PAP therapy, it took a mean of 8.1 (SD 9.3) days and median 6.0 days (IQR 4.0) from OSA diagnosis to PAP therapy initiation.ConclusionsThese results demonstrate the possibility of a highly efficient, patient-centered pathway for OSA workup and treatment. Such findings support pathways that could increase access to care, reduce loss to follow-up, and reduce health burden and overall cost. The program’s ability to efficiently diagnose patients who otherwise may have not been diagnosed with OSA is important, especially during a pandemic, as the United States shifted to remote care models and may sustain this direction. The potential economic and clinical impact of the program’s short and efficient journey time and low attrition rate should be further examined in future analyses. Future research also should examine how a fast and positive diagnosis experience impacts success rates for PAP therapy initiation and adherence.Trial RegistrationClinicalTrials.gov NCT04599803; https://clinicaltrials.gov/ct2/show/NCT04599803

Perioperative care for major elective surgery: a survey of Brazilian physiotherapists

Abstract Introduction: Major surgeries are highly complex procedures and have a higher incidence of respiratory morbidity and mortality compared to other types of surgery. Postoperative pulmonary complications (PPC) are common after such surgeries and are associated with increased hospital stay, health care costs and surgical patient mortality. Objective: To investigate the most commonly used physical therapy techniques for the prevention and treatment of PPC among thoracic and abdominal surgery patients in all regions of Brazil. Methods: A total of 489 randomly selected physiotherapists who provided perioperative care for patients undergoing elective abdominal, thoracic or cardiac surgeries participated in this study. A questionnaire with nine questions about routine care and therapeutic choices for the surgical population was developed and assessed by 10 specialists before being administered to the physiotherapists. Results: Among the physiotherapists (63% with at least 5 years of experience with surgical patients), 50.9% considered the patient’s surgical risk in their treatment either always or often. A total of 53.8% patients were treated by the physiotherapist following a physician’s prescription. The most mentioned physical therapy techniques used to prevent PPC were postoperative mobilization/exercises (59.3%), postoperative lung expansion (52.8%), and preoperative advice (50.7%). In addition, 80.6% of the physiotherapists believe that incentive spirometry prevents PPC, while 72.8% expected this effect from positive airway pressure devices. Conclusion: Most physiotherapists in Brazil who work with surgical patients offer preoperative professional advice, use postoperative early mobilization and lung expansion techniques to prevent PPC, and consider the patient's surgical risk during treatment. In addition, some physical therapy sessions are routinely performed preoperatively.

The effect of continuous positive airway pressure and mandibular advancement device on sleep bruxism intensity in obstructive sleep apnea patients.

We aimed to evaluate and compare the effects of continuous positive airway pressure (CPAP) and mandibular advancement device (MAD) in reducing the intensity of sleep bruxism (SB) in patients with obstructive sleep apnea (OSA). Forty-eight adults with OSA were subjected to single-night full polysomnography (PSG) in the Sleep Laboratory of the Wroclaw Medical University. The respiratory events and bruxism episodes were scored according to the standards of the American Academy of Sleep Medicine. The patients were assigned to the CPAP treatment or the MAD treatment in accordance to apnea–hypopnea index (AHI). The second PSG examination was conducted during the MAD or CPAP treatment to assess the effect of treatment on bruxism episode index (BEI) and AHI. The mean AHI and mean BEI in the study material were estimated to be 30.05 ± 15.39 and 5.10 ± 5.31, respectively. The bruxism parameters were significantly decreased in both the CPAP and MAD groups. Compared to the MAD, the CPAP treatment was more effective in reducing AHI; however, there was no significant difference in effectiveness of CPAP and MAD treatment in BEI reduction. Both CPAP and MAD treatments were effective against SB coexisting with OSA. Due to the application of these treatment options, the risk of OSA should be estimated in patients with SB.

Chapter 15 - Sleep and breathing disorders in heart failure

Sleep disorders are prevalent in heart failure and include insomnia, poor sleep architecture, periodic limb movements and periodic breathing, and encompass both obstructive (OSA) and central sleep apnea (CSA). Polysomnographic studies show excess light sleep and poor sleep efficiency particularly in those with heart failure. Multiple studies of consecutive patients with heart failure show that about 50% of patients suffer from either OSA or CSA. While asleep, acute pathological consequences of apneas and hypopneas include altered blood gases, sleep fragmentation, and large negative swings in intrathoracic pressure. These pathological consequences are qualitatively similar in both types of sleep apnea, though worse in OSA than CSA. Sleep apnea results in oxidative stress, inflammation, and endothelial dysfunction, best documented in OSA. Multiple studies show that both OSA and CSA are associated with excess hospital readmissions and premature mortality. However, no randomized controlled trial (RCT) has been reported for OSA, but sensitivity analysis of two randomized controlled trials has concluded that use of positive airway pressure devices is associated with excess mortality in patients with heart failure and CSA. Phrenic nerve stimulation has shown improvement in sleep apnea events and daytime sleepiness; however, no randomized controlled trials have demonstrated improvement in survival in patients with heart failure. The correct identification and treatment of heart failure patients with sleep and breathing disorders could affect the long-term outcomes of these patients.

APAP, BPAP, CPAP, and New Modes of Positive Airway Pressure Therapy.

Positive airway pressure (PAP) is the primary treatment of sleep-disordered breathing including obstructive sleep apnea, central sleep apnea, and sleep-related hypoventilation. Just as clinicians use pharmacological mechanism of action and pharmacokinetic data to optimize medication therapy for an individual, understanding how PAP works and choosing the right mode and device are critical to optimizing therapy in an individual patient. The first section of this chapter will describe the technology inside PAP devices that is essential for understanding the algorithms used to control the airflow and pressure. The second section will review how different comfort settings including ramp and expiratory pressure relief and modes of PAP therapy including continuous positive airway pressure (CPAP), autotitrating CPAP, bilevel positive airway pressure, adaptive servoventilation, and volume-assured pressure support control the airflow and pressure. Proprietary algorithms from several different manufacturers are described. This chapter derives its descriptions of algorithms from multiple sources including literature review, manufacture publications and websites, patents, and peer-reviewed device comparisons and from personal communication with manufacturer representatives. Clinical considerations related to the technological aspects of the different algorithms and features will be reviewed.

Outcome of Locally Assembled Continous Positive Airway Pressure Device in Neonates with Respiratory Distress in Low Resource Setting

Respiratory distress is the most frequent cause of neonatal admission in neonatal intensive care unit (NICU). Continuous Positive Airway Pressure (CPAP) is an effective mode of treatment in newborn with respiratory distress. CPAP is the application of positive pressure to the airways of spontaneously breathing patient throughout the respiratory cycle. Low cost CPAP can be locally assembled and used in neonates with respiratory distress to reduce the mortality. This is a cross sectional descriptive study conducted in NICU of Nepal Medical College Teaching Hospital from the period of June 2021 to September 2021 to assess the outcome of locally assembled CPAP. A total of 96 newborns with respiratory distress were included in the study. Severity of respiratory distress was assessed by Downes score. Downes score before and after CPAP were recorded. Newborn with Downes score of ≥4 was started with locally assembled CPAP. Outcome was taken as improvement when the respiratory distress was decreased with Downes score&lt;4. And it was taken as a failure when baby required mechanical ventilation. Mean Downes score before starting CPAP was 4.81 and after CPAP was 0.51. Mean CPAP pressure was 4.27cm of water. Outcome of study showed, 80 (83.3%) babies were improved, 7 (7.3%) had failed CPAP who required mechanical ventilation and 1 (1%) baby expired. In conclusion, locally assembled CPAP shown to be equally effective as standard CPAP device and can be used as an effective alternative to mechanical ventilator in developing country with limited resource setting.