Respiratory Events In Patients Research Articles

Association of SGLT2i vs DPP4i With Pneumonia, COVID-19, and Other Adverse Respiratory Events in Patients With Type 2 Diabetes Mellitus: A Systematic Review and Meta-analysis

ObjectiveOur aim in this study was to systematically assess the association of sodium-glucose cotransporter-2 inhibitors (SGLT2i) vs dipeptidyl peptidase-4 inhibitors (DPP4i) with pneumonia, COVID-19, and adverse respiratory events in patients with type 2 diabetes mellitus (DM). MethodsPubMed, Embase, and Cochrane Library databases were retrieved to include studies on DM patients receiving SGLT2i (exposure group) or DPP4i (control group). Stata version 15.0 statistical software was used for the meta-analysis. ResultsTen studies were included, all 10 of which were used for the qualitative review and 7 for the meta-analysis. According to the meta-analysis, patients receiving SGLT2i had a lower incidence of pneumonia (odds ratio [OR] 0.62, 95% confidence interval [CI] 0.51 to 0.74) and pneumonia risk (OR 0.63, 95% CI 0.60 to 0.68, p=0.000) compared with those receiving DPP4i. The same situation was seen for mortality for pneumonia (OR 0.49, 95% CI 0.39 to 0.60) and pneumonia mortality risk (OR 0.47, 95% CI 0.42 to 0.51). There was lower mortality due to COVID-19 (OR 0.31, 95% CI 0.28 to 0.34) and a lower hospitalization rate (OR 0.61, 95% CI 0.56 to 0.68, p=0.000) and incidence of mechanical ventilation (OR 0.69, 95% CI 0.58 to 0.83, p=0.000) due to COVID-19 in patients with type 2 DM receiving SGLT2i. Qualitative analysis results show that SGLT2i was associated with a lower incidence of COVID-19, lower risk of obstructive airway disease events, and lower hospitalization rate of health-care–associated pneumonia than DPP4i. ConclusionIn patients with type 2 DM, SGLT2i are associated with a lower risk of pneumonia, COVID-19, and mortality than DPP4i.

Value of integrated pulmonary index monitoring for the detection of adverse respiratory events in patients undergoing sedation for gastrointestinal system endoscopy.

To determine if the integrated pulmonary index detects changes in ventilation status early in patients undergoing gastrointestinal endoscopy under sedation, and to determine the risk factors affecting hypoxia. The retrospective study was conducted at the endoscopy unit of a tertiary university hospital in Turkey and comprised data between October 2018 and December 2019 related to patients of either gender aged >18 years who were assessed as American Society of Anaesthesiologists grade I-III and underwent elective lower and upper gastrointestinal endoscopy. Monitoring was done with capnography in addition to standard procedures. Data was analysed using SPSS 23. Of the 154 patients, 94(%) were females and 60(%) were males. The overall mean age was 50.88±11.8 years (range: 20-70 years). Mean time under anaesthesia was 23.58±4.91 minutes and mean endoscopy time was 21.73±5.06 minutes. During the procedure, hypoxia was observed in 42(27.3%) patients, severe hypoxia in 23(14.9%) and apnoea in 70(45.5%). Mean time between apnoea and hypoxia was 12.59±7.99 seconds, between apnoea and serious hypoxia 21.07±17.64 seconds, between integrated pulmonary index score 1 and hypoxia 12.91±8.17 sec, between integrated pulmonary index score 1 and serious hypoxia 21.59±14.13 seconds, between integrated pulmonary index score <7 and hypoxia 19.63±8.89 seconds, between integrated pulmonary index score <7 and serious hypoxia 28.39±12.66 seconds, between end-tidal carbon dioxide and hypoxia 12.95±8.33 seconds, and between end-tidal carbon dioxide and serious hypoxia 21.29±7.55 seconds. With integrated pulmonary index score 1, sensitivity value for predicting hypoxia and severe hypoxia was 88.1% and 95.7%, respectively, and specificity was 67% and 60.3%, respectively. With integrated pulmonary index score <7, the corresponding values were 100%, 100%, 42% and 64.1%, respectively. Capnographic monitoring, especially the follow-up integrated pulmonary index score, was found to be valuable and reliable in terms of finding both time and accuracy of the risk factor in the diagnosis of respiratory events.

Variation of respiratory and pulse events in multiple system atrophy

IntroductionA study is eagerly awaited that will reveal the unknown mechanisms of multiple system atrophy (MSA), in which the risk of sudden death is the greatest during sleep. The blunted pulse response to nocturnal respiratory events suggests an abnormal cardiac response to a sleep-related breathing disorder. Patients with MSA have a lower pulse event index (PEI), despite a greater hypoxic burden and a similar frequency of respiratory events. However, the evidence is speculative and not directly proven, and many limitations require further study. MethodsWe conducted a retrospective analysis of 26 patients with MSA who had undergone overnight oximetry between April 2016 and December 2022. ResultsThe median 4% oxyhemoglobin desaturation index (ODI) was 11.6/h, the 6-bpm PEI was 8.9/h, and the PEI/ODI ratio was as low as 0.91. There were three patients with suspected sudden death; all had low PEI/ODI ratios. The PEI/ODI ratio was followed over time in seven patients, all of whom had a decrease in the ratio. However, the PEI was higher than the ODI in 12/26 (46%) of the patients. ConclusionA low PEI/ODI ratio, reflecting a blunted pulse response to nocturnal respiratory events in patients with MSA, may indicate a worse prognosis. This finding and the significance of the longitudinal decrease in the PEI/ODI ratio will require a prospective study.

The effect of longitudinal sleep monitoring on clinician agreement in obstructive sleep apnea diagnosis: The ELSA study.

There is strong evidence for clinically relevant night-to-night variability of respiratory events in patients with suspected obstructive sleep apnea. Sleep experts retrospectively evaluated diagnostic data in 56 patients with suspected obstructive sleep apnea. Experts were blinded to the fact that they were diagnosing the same case twice, once based on a short report of a single in-laboratory respiratory polygraphy and once with the additional information of 14 nights of pulse oximetry at home. All experts (n = 22) were highly qualified, 13 experts (59.1%) treated > 100 patients with suspected obstructive sleep apnea per year. In 12 patients, the apnea-hypopnea index in the respiratory polygraphy was < 5 per hr, but the mean oxygen desaturation index of 14 nights of pulse oximetry was ≥ 5 per hr. The additional information of 14 nights of pulse oximetry helped to diagnose obstructive sleep apnea with a 70% consensus in two of those patients (16.7% [95% confidence interval: 4.7/44.8]). In eight patients, experts could not agree to a 70% consensus regarding continuous positive airway pressure therapy recommendation after respiratory polygraphy. The additional information of multiple-night testing led to a consensus in three of those cases (37.5% [95% confidence interval: 14/69]). Change of obstructive sleep apnea diagnosis and continuous positive airway pressure recommendation was significantly negatively associated with the number of treated obstructive sleep apnea patients > 100 per year compared with 0-29 patients per year (Coef. [95% confidence interval] -0.63 [-1.22/-0.04] and -0.61 [-1.07/-0.15], respectively). Experts found already a high level of consensus regarding obstructive sleep apnea diagnosis, severity and continuous positive airway pressure recommendation after a single respiratory polygraphy. However, longitudinal sleep monitoring could help increase consensus in selected patients with diagnostic uncertainty.

Temporal association between leg movements and respiratory events in patients with obstructive sleep apnea: description and differences between the AASM and WASM scoring criteria

PurposeTo describe the temporal association between leg movements (LMs) and respiratory events in patients with obstructive sleep apnea (OSA), and to quantify the difference in scoring respiratory-related leg movement (RRLM) between the American Academy of Sleep Medicine (AASM) criterion and the criterion recommended by the World Association of Sleep Medicine (WASM).MethodsPatients with OSA who presented with > 10 LMs of any type per hour of sleep were included in this study. For each participant, RRLMs were scored using both the AASM criterion and the recommended WASM criterion. The occurrence of LMs in relation to respiratory events and the difference in scoring RRLM between the AASM criterion and the criterion recommended by the WASM were quantified.ResultsIn 32 patients enrolled, mean age was 48.1 ± 11.0 years and 78% were men. LMs were significantly more frequent after respiratory events, followed by before respiratory events, and were rare during respiratory events (P < 0.01). Compared with the AASM criterion, more LMs were classified as RRLMs based on the recommended WASM criterion (P = 0.01).ConclusionLMs are more frequent after respiratory events than before and during respiratory events, and more LMs are scored as RRLMs based on the recommended WASM criterion than based on the AASM criterion.

Incidence and Nature of Respiratory Events in Patients Undergoing Bronchoscopy Under Conscious Sedation.

During diagnostic bronchoscopies, conscious sedation improves patient tolerance, but it can contribute to hypercapnia and hypoxia by various mechanisms including depression of ventilatory drive. This prospective study was undertaken to determine the frequency of respiratory events and associated oxygen desaturations during bronchoscopy with conscious sedation. The Nox-T3 monitoring system was placed before starting the bronchoscopy and remained in place for 30 minutes following the procedure. The primary endpoint was the occurrence of obstructive and central apneic events during bronchoscopy under conscious sedation. Obstructive events (apnea and hypopnea) occurred in 100% of patients (n=31), and central apneas occurred in 58% of patients (n=18) during the procedure with a median of 9 and 2 events per patient, respectively. During recovery, a significant proportion of patients had detectable obstructive (86%) and central (36%) events. Higher body mass index was associated with oxygen desaturation to <90% and with the need for escalation of care. Furthermore, a conscious sedation regimen that included propofol was significantly associated with central apneic events. Respiratory events are common during and immediately postprocedure after conscious sedation for bronchoscopy. Most events are obstructive, and the use of propofol predisposes to central apneas during the procedure. Both types of events are associated with a higher body mass index. Oxygen desaturation to <90% triggers escalation of care. A further prospective study will be required to determine the clinical significance of these apneic events and whether alleviating these events will improve the safety and outcomes of bronchoscopic procedures performed under conscious sedation.

Respiratory Event Detection During Sleep Using Electrocardiogram and Respiratory Related Signals: Using Polysomnogram and Patch-Type Wearable Device Data.

This paper presents an automatic algorithm for the detection of respiratory events in patients using electrocardiogram (ECG) and respiratory signals. The proposed method was developed using data of polysomnogram (PSG) and those recorded from a patch-type device. In total, data of 1,285 subjects were used for algorithm development and evaluation. The proposed method involved respiratory event detection and apnea-hypopnea index (AHI) estimation. Handcrafted features from the ECG and respiratory signals were applied to machine learning algorithms including linear discriminant analysis, quadratic discriminant analysis, random forest, multi-layer perceptron, and the support vector machine (SVM). High performance was demonstrated when using SVM, where the overall accuracy achieved was 83% and the Cohen's kappa was 0.53 for the minute-by-minute respiratory event detection. The correlation coefficient between the reference AHI obtained using the PSG and estimated AHI as per the proposed method was 0.87. Furthermore, patient classification based on an AHI cutoff of 15 showed an accuracy of 87% and a Cohen's kappa of 0.72. The proposed method increases performance result, as it records the ECG and respiratory signals simultaneously. Overall, it can be used to lower the development cost of commercial software owing to the use of open datasets.

Postextubation respiratory events in patients admitted to the intensive care unit: a prospective pilot study using overnight respiratory polygraphy.

Background Before the main trial in which respiratory polygraphy will be used to evaluate postextubation sleep apnea in critically ill patients, we performed a prospective pilot study to ensure that any issues with the conduct of the trial would be identified.Methods In the present study, 13 adult patients who had received mechanical ventilation for ≥24 hours were prospectively recruited. Among the patients, 10 successfully completed respiratory polygraphy on the first or second night after extubation. Data regarding the types and doses of corticosteroids, analgesics, sedatives, and muscle relaxants as well as the methods of oxygen delivery were recorded.Results During the night of respiratory polygraphy, all 10 patients received supplemental oxygen (low-flow oxygen, n=5; high-flow oxygen, n=5), and seven patients received intravenous corticosteroids. Three of the 10 patients had a respiratory event index (REI) ≥5/hr. All respiratory events were obstructive episodes. None of the patients receiving high-flow oxygen therapy had an REI ≥5/hr. Two of the seven patients who received corticosteroids and one of the other three patients who did not receive this medication had an REI ≥5/hr. Although low- or high-flow oxygen therapy was provided, all patients had episodes of oxygen saturation (SpO2) <90%. Two of the three patients with an REI ≥5/hr underwent in-laboratory polysomnography. The patients’ Apnea-Hypopnea Index and REI obtained via polysomnography and respiratory polygraphy, respectively, were similar.Conclusions In a future trial to evaluate postextubation sleep apnea in critically ill patients, pre-stratification based on the use of corticosteroids and high-flow oxygen therapy should be considered.

The Accuracy of Repeated Sleep Studies in OSA: A Longitudinal Observational Study With 14 Nights of Oxygen Saturation Monitoring

Strong evidence exists for clinically relevant night-to-night variability of respiratory events in patients with suspected OSA. How many sleep study nights are required to diagnose OSA accurately? Patients with suspected OSA underwent up to 14 nights of pulse oximetry (PO) at home and one night of in-hospital respiratory polygraphy (RP). The accuracy of each of the 13 sleep study nights was analyzed using the mean oxygen desaturation index 3%(ODI3%) of all 14 nights as a reference. Multiple regression analyses assessed possible predictors for night-to-night variability. One hundred three patients underwent in-hospital RP. Using only the results of the RP, 19.7%were misdiagnosed using an ODI3% cutoff of 15/h. One hundred eight patients underwent properly performed PO studies at home with a coefficient of variation (CV) of 31.5%(SD, 14.7%) across all nights. The first PO night demonstrated a sensitivity of 71.4%(95%CI, 55.4%-84.3%) and a specificity of 89.4%(95%CI, 79.4%-95.6%) to diagnose moderate OSA. Using only the first PO night, the negative predictive value was 83.1%. Adding a second recording night increased sensitivity up to 88.1%(95%CI, 74.4%-96.0%) with a slightly lower specificity of 85.9%(95%CI, 74.9%-93.4%). The ODI3% of the in-hospital RP showed an independent negative association to the log-transformed CV (exponentiated coefficient, 0.989; 95%CI, 0.984-0.995). One single night of in-hospital RP may miss relevant OSA. Multiple study nights, for example, using ambulatory oxygen saturation monitoring, increase accuracy for diagnosing moderate OSA. ClinicalTrials.gov; No.: NCT03819361; URL: www.clinicaltrials.gov.

Postoperative respiratory state assessment using the Integrated Pulmonary Index (IPI) and resultant nurse interventions in the post-anesthesia care unit: a randomized controlled trial

Although postoperative adverse respiratory events, defined by a decrease in respiratory rate (RR) and/or a drop in oxygen saturation (SpO2), occur frequently, many of such events are missed. The purpose of the current study was to assess whether continuous monitoring of the integrated pulmonary index (IPI), a composite index of SpO2, RR, end-tidal PCO2 and heart rate, alters our ability to identify and prevent adverse respiratory events in postoperative patients. Eighty postoperative patients were subjected to continuous respiratory monitoring during the first postoperative night using RR and pulse oximetry and the IPI monitor. Patients were randomized to receive intervention based on standard care (observational) or based on the IPI monitor (interventional). Nurses were asked to respond to adverse respiratory events with an intervention to improve the patient’s respiratory condition. There was no difference in the number of patients that experienced at least one adverse respiratory event: 21 and 16 in observational and interventional group, respectively (p = 0.218). Compared to the observational group, the use of the IPI monitor led to an increase in the number of interventions performed by nurses to improve the respiratory status of the patient (average 13 versus 39 interventions, p < 0.001). This difference was associated with a significant reduction of the median number of events per patient (2.5 versus 6, p < 0.05) and a shorter median duration of events (62 s versus 75 s, p < 0.001). The use of the IPI monitor in postoperative patients did not result in a reduction of the number of patients experiencing adverse respiratory events, compared to standard clinical care. However, it did lead to an increased number of nurse interventions and a decreased number and duration of respiratory events in patients that experienced postoperative adverse respiratory events.

Sleep Electroencephalographic Response to Respiratory Events in Patients With Moderate Sleep Apnea-Hypopnea Syndrome.

Sleep apnea–hypopnea syndrome is a common breathing disorder that can lead to organic brain injury, prevent memory consolidation, and cause other adverse mental-related complications. Brain activity while sleeping during respiratory events is related to these dysfunctions. In this study, we analyzed variations in electroencephalography (EEG) signals before, during, and after such events. Absolute and relative powers, as well as symbolic transfer entropy (STE) of scalp EEG signals, were calculated to unveil the activity of brain regions and information interactions between them, respectively. During the respiratory events, only low-frequency power increased during rapid eye movement (REM) stage (δ-band absolute and relative power) and N1 (δ- and θ-band absolute power, δ-band relative power) sleep. But absolute power increased in low- and medium-frequency bands (δ, θ, α, and σ bands), and relative power increased mainly in the medium-frequency band (α and σ bands) during stage N2 sleep. After the respiratory events, absolute power increased in all frequency bands and sleep stages, but relative power increased in medium and high frequencies. Regarding information interactions, the β-band STE decreased during and after events. In the γ band, the intrahemispheric STE increased during events and decreased afterward. Moreover, the interhemisphere STE increased after events during REM and stage N1 sleep. The EEG changes throughout respiratory events are supporting evidence for previous EEG knowledge of the impact of sleep apnea on the brain. These findings may provide insights into the influence of the sleep apnea–hypopnea syndrome on cognitive function and neuropsychiatric defects.

Temporal Association Between Respiratory Events and Reflux in Patients With Obstructive Sleep Apnea and Laryngopharyngeal Reflux.

The aim of the current study was to test the hypothesis that there is a temporal correlation between reflux episodes and respiratory events in patients with laryngopharyngeal reflux and obstructive sleep apnea. Adults with clinically diagnosed laryngopharyngeal reflux confirmed by two validated instruments (reflux symptom index ≥ 13 and reflux finding score ≥ 7) and obstructive sleep apnea (OSA) underwent full polysomnography with concomitant and synchronized multichannel intraluminal impedance-pH esophageal monitoring. The apnea-hypopnea and arousal indexes that occurred 15, 30, and 45 minutes before and after each reflux episode were recorded and compared to full-night apnea and hypopnea and arousal index. We studied 27 patients (14 males, age 51.7 ± 9.1 years, body mass index 32.4 ± 4.2 kg/m²) with laryngopharyngeal reflux (reflux symptom index 16 ± 2 and reflux finding score 12 ± 3) and OSA (apnea-hypopnea index = 32.3 ± 28.4 events/h). We evaluated 102 reflux episodes. Almost half of the reflux episodes occurred while awake (43.1%) and only five reflux episodes (4.9%) occurred during an obstructive respiratory event. The apnea and hypopnea and arousal indexes 15, 30, and 45 minutes before and after reflux episodes were lower than full-night apnea and hypopnea and arousal indexes, respectively. Among patients with well-established laryngopharyngeal reflux and OSA, there is no temporal association between reflux and obstructive respiratory events. Even though the data comprised a small sample size, it seems that a more complex mechanism is involved with these two highly prevalent diseases.

Sleep duration and architecture during ASV for central sleep apnoea in systolic heart failure

BackgroundAdaptive servoventilation (ASV) effectively treats nocturnal respiratory events in patients with heart failure and reduced ejection fraction (HFrEF) and central sleep apnoea (CSA), but increased mortality has been reported. This study investigated changes in sleep architecture during ASV treatment in HFrEF patients. MethodsA retrospective analysis of polysomnographic datasets for 30 ASV-treated patients with stable HFrEF and moderate-to-severe CSA was performed, including blinded analyses of total sleep time (TST), and percentage of REM and non-REM sleep (stages N1-N3). ResultsFollow-up was 109 ± 32 days; mean device usage was 6.0 ± 1.1 h/day. During ASV there was reduction of N1 (34 ± 20%/TST to 13 ± 5%/TST, p < 0.001) and N3 sleep (4 ± 6%/TST to 1 ± 4%/TST, p = 0.020), and increase of N2 (44 ± 14%/TST to 62 ± 7%/TST, p < 0.001) and REM-sleep (18 ± 8%/TST to 24 ± 6%/TST, p = 0.002). ConclusionsDisturbances of sympatho-vagal balance during ASV might help explain increased mortality during ASV. Since sympathetic tone is highest in REM-sleep and vagal predominance occurs during N3 sleep, these findings generate new hypotheses for the increased mortality seen in SERVE-HF.

Capnography monitoring of patients with obstructive sleep apnea in the post-anesthesia care unit: a best practice implementation project.

The prevalence of OSA is substantial in North America. Post-operative patients with OSA are at risk for respiratory complications, but about 60% of surgical patients with this condition go undiagnosed. If the presence of sleep apnea is known, non-invasive capnography monitoring can be applied post-operatively to help detect early respiratory compromise during the recovery phase. The STOP-Bang Questionnaire, a validated screening tool to evaluate the risk of OSA, can efficiently be used as part of the pre-surgical evaluation. The aim of this project was to improve safety by averting post-operative respiratory events in patients with obstructive sleep apnea (OSA) through early detection of compromise during recovery from anesthesia. Specific objectives focused on implementing nurse-initiated capnography monitoring of patients with OSA in two post-anesthesia care units and, when indicated, expediently communicating abnormal end-tidal carbon dioxide excursions. Strategies and audit data were organized and evaluated using the Joanna Briggs Institute's Getting Research into Practice (GRiP) and Practical Application of Clinical Evidence Systems (PACES) tools. Medical record review was used for the baseline audit and three follow-up compliance audits of evidence-based practice. Multiple teaching methodologies were employed to reach and engage post-anesthesia care unit nurses. Equipment was maintained at the point of care. Nurses' participation in the project was voluntary. There was nearly full compliance with the new practice of initiating capnography, when indicated. Compliance with escalating abnormal capnography results with associated concerning assessment findings was 100%, but the escalation sample size was only two patients. Patients with known OSA benefited from non-invasive capnography monitoring during recovery from anesthesia because post-anesthesia care unit nurses were empowered to initiate evidence-based technology. Expedient adoption of the new practice was due to comprehensive nurse education, familiarity with a similar capnography monitoring process and the value nurses placed on capnography as another assessment tool to safeguard patients. A larger sample of patients is needed to evaluate compliance with escalating concerning findings to providers. Sustainability will be impacted if the post-anesthesia care unit's standards of care include capnography for patients with OSA.

Signal-averaged P wave area increases during respiratory events in patients with paroxysmal atrial fibrillation and obstructive sleep apnea.

P wave characteristics change during simulated apneic events in individuals with atrial fibrillation (AF). This study sought to assess whether similar changes occur during nocturnal respiratory events in patients with AF and obstructive sleep apnea (OSA). Thirty-five individuals with severe OSA who underwent formal polysomnography and subsequent AF ablation were compared to a matched group without AF. Electrocardiographic segments from each polysomnogram corresponding to the following events were identified: period of wakefulness closest to the initial onset of sleep (baseline-awake), first respiratory event, respiratory event with the lowest nadir oxygen saturation, longest respiratory event, and last respiratory event. Signal-averaged P wave duration and signal-averaged positive P wave area (amplitude*duration for positive P wave amplitudes) were extracted using custom software. P wave characteristics during respiratory events and the baseline-awake condition were compared. Compared to the baseline-awake condition, the signal-averaged positive P wave area was significantly greater during the longest event and the event with the lowest oxygen saturation in those with AF, but not in those without AF. There were no significant differences in signal-averaged P wave duration for any respiratory event compared to the baseline-awake condition, regardless of AF status. In patients with paroxysmal AF and obstructive sleep apnea, the signal-averaged positive P wave area is greater during certain respiratory events than during wakefulness. This finding may reflect the acute impact on right atrial volume of increased venous return associated with respiratory events and could be useful to assess AF risk in sleep apnea and to monitor response to treatment.

Incidence and Risk Factors for Perioperative Cardiovascular and Respiratory Adverse Events in Pediatric Patients With Congenital Heart Disease Undergoing Noncardiac Procedures.

While mortality and adverse perioperative events after noncardiac surgery in children with a broad range of congenital cardiac lesions have been investigated using large multiinstitutional databases, to date single-center studies addressing adverse outcomes in children with congenital heart disease (CHD) undergoing noncardiac surgery have only included small numbers of patients with significant heart disease. The primary objective of this study was to determine the incidences of perioperative cardiovascular and respiratory events in a large cohort of patients from a single institution with a broad range of congenital cardiac lesions undergoing noncardiac procedures and to determine risk factors for these events. We identified 3010 CHD patients presenting for noncardiac procedures in our institution over a 5-year period. We collected demographic information, including procedure performed, cardiac diagnosis, ventricular function as assessed by echocardiogram within 6 months of the procedure, and classification of CHD into 3 groups (minor, major, or severe CHD) based on residual lesion burden and cardiovascular functional status. Characteristics related to conduct of anesthesia care were also collected. The primary outcome variables for our analysis were the incidences of intraoperative cardiovascular and respiratory events. Univariable and multivariable logistic regressions were used to determine risk factors for these 2 outcomes. The incidence of cardiovascular events was 11.5% and of respiratory events was 4.7%. Univariate analysis and multivariable analysis demonstrated that American Society of Anesthesiologists (≥3), emergency cases, major and severe CHD, single-ventricle physiology, ventricular dysfunction, orthopedic surgery, general surgery, neurosurgery, and pulmonary procedures were associated with perioperative cardiovascular events. Respiratory events were associated with American Society of Anesthesiologists (≥4) and otolaryngology, gastrointestinal, general surgery, and maxillofacial procedures. Intraoperative cardiovascular events and respiratory events in patients with CHD were relatively common. While cardiovascular events were highly associated with cardiovascular status, respiratory events were not associated with cardiovascular status.

Acute respiratory events in patients with bronchiectasis-COPD overlap syndrome: A population-based cohort study.

The clinical phenotypes of chronic obstructive pulmonary disease (COPD) are related to various outcomes. We investigated the risk of acute respiratory events in patients with bronchiectasis-COPD overlap syndrome (BCOS) in Taiwan. We included 3955 patients who received diagnoses of COPD and bronchiectasis from 2000 to 2007 from the Taiwan Longitudinal Health Insurance Database in the BCOS cohort. In the comparison cohort, we included patients with COPD but without bronchiectasis at a ratio of 4:1, frequency matched by age, sex, and index year with each patient with BCOS. We followed both cohorts for 5 years to investigate the incidence and risk of acute respiratory events in the BCOS cohort relative to the comparison cohort, the incidence rate ratios (IRRs) and corresponding 95% confidence intervals (CIs) were determined using Poisson regression models. The BCOS cohort experienced more episodes of acute respiratory events than did the comparison cohort (16.4 vs 5.52 per 100 person-y). After adjustment for potential covariates, the BCOS cohort had a 2.20-fold higher risk of pneumonia (adjusted IRR = 2.20, 95% CI = 2.06-2.34), a 3.88-fold higher risk of acute exacerbation (adjusted IRR = 3.88,95% CI = 3.64-4.13), a 1.74-fold higher risk of acute respiratory failure (adjusted IRR = 1.74,95% CI = 1.47-2.06), and a 1.99-fold higher risk of cardiopulmonary arrest (adjusted IRR = 1.99,95% CI = 1.81-2.20) than did the comparison cohort. The patients with BCOS had a higher risk of acute respiratory events than did COPD patients without bronchiectasis.

Does Obstructive Sleep Apnea (OSA) Increase the Risk of Post-Operative Respiratory Complications after Bariatric Surgery?

Background: OSA affects up to quarter of general population. It is associated with morbid obesity with a higher morbidity and mortality rates. STOP Bang questionnaire is a validated method for OSA screening. OSA patients are at high risk of developing airway obstruction, cardiac events, congestive heart failure, stroke and desaturation post operatively. The aim of this study is to evaluate adverse respiratory events in patients undergoing bariatric surgery in relation to risk of OSA using Stop Bang questionnaire. Methods: This prospective double cohort study was conducted in Tanta University Hospital from Marchto August 2017. During the preoperative assessment, STOP-BANG questionnaire was performed. After extubation, patients were transferred to PACU unit. Respiratory complications were assessed thereafter. Based on STOP-BANG score, patients were divided into two groups, high risk of OSA with STOP-BANG > 3 (Group I) and low risk of OSA with STOP-BANG Results: 104 patients were included in this study. Group I had more comorbidities in the form of CAD (15% versus 2%, P 0.001). Higher number of respiratory complications was noted in high-risk group (31 patients, 59%) compared to (24 patients, 46%) in group II yet, it was not significant. Conclusion: Obese patients with STOP-BANG score > 3 undergoing bariatric surgery are associated with hypertension, dyslipidemia, CAD, and renal insufficiency. High-risk OSA obese patients are at higher risk of developing respiratory compilations like inability to breathe deeply and hypoxia in postoperatively.

Efficacy and safety of etomidate-based sedation compared with propofol-based sedation during ERCP in low-risk patients: a double-blind, randomized, noninferiority trial

Etomidate is a short-acting intravenous hypnotic with a safety profile that is superior to alternative drugs such as propofol. However, there is a lack of evidence on the safety of etomidate in ERCP. The objective of this study was to compare efficacy and safety profiles of etomidate and propofol for endoscopic sedation. This single-center, randomized, double-blind, noninferiority trial included patients with American Society of Anesthesiologists (ASA) physical status I to II who had been scheduled for ERCP. All patients received .05 mg/kg midazolam intravenously as pretreatment before receiving etomidate or propofol. Either etomidate or propofol was then administered according to group allocation. The primary endpoint was an overall respiratory event. A noninferiority margin of 10% was assumed. Sixty-three and 64 patients were enrolled in the etomidate and propofol groups, respectively. Respiratory events were identified in 10 patients (15.6%) in the etomidate group and 16 patients (25.4%) on the propofol group, with a rate difference of -9.8% (1-sided 97.5% confidence interval, -∞ to 4.2%). The overall incidence of cardiovascular events tended to be higher in the etomidate group (67.2% vs 50.8%, P= .060). In particular, tachycardia (heart rate > 100 beats/min) was more common in the etomidate group than in the propofol group (64.1% vs 34.9%, P= .001). Transient hypotension tended to be less common in the etomidate group (6.3 vs 15.9%, P= .084). Etomidate-based sedation during ERCP was noninferior to propofol-based sedation in terms of the overall incidence of respiratory events in patients with ASA physical status I to II. (International Clinical Trials Registry Platform number: KCT0001926.).

Utility of end-tidal carbon dioxide monitoring in intramuscular ketamine sedation in the pediatric emergency department

Purpose Recently, the use of end-tidal carbon dioxide (ETCO2) monitoring has been suggested for early detection of hypoventilation over oxygen saturation (SPO2) monitoring. We aimed to determine the usefulness of capnography in monitoring patients sedated using intramuscular (IM) ketamine in the pediatric emergency department (ED). Methods This study retrospectively reviewed medical records of patients younger than 16 years who were sedated using IM ketamine and whose ETCO2 values were documented in the ED. Age, sex, American Society of Anesthesiologists physical status classification (ASA classification), and purpose of sedation were investigated. Vital signs were recorded at pre-sedation, 5 and 10 minutes after sedation, and after recovery. Hypoventilation was defined as S P O2 < 95%, ETCO2 ≥ 50 mmHg or ≤30 mmHg, or increase in ETCO2 ≥ 10 mmHg from the baseline without tachypnea. Results A total of 49 patients were investigated; 42 of them belonged to ASA classification I, and 7 to II. There was no patient with SPO2 < 95%, or ETCO2 ≥ 50 mmHg, or increase in ETCO2 ≥ 10 mmHg from the pre-sedation value. However, 5 patients had an ETCO2 ≤ 30 mmHg, and 4 of them (8.2%) had normal respiratory rate and were suitable for hypopneic hypoventilation. Ten patients showed abnormal range of ETCO2 (normal range, 35–45 mmHg), but did not meet the definition of hypoventilation. No one had clinically serious respiratory events. Conclusion During sedation using IM ketamine, 8.2% of the patients had hypopneic hypoventilation without hypoxemia, and they were all younger than 36 months. Capnography for patients sedated using IM ketamine in the ED is useful in detecting hypopneic hypoventilation, and has the potential for preventing clinically serious respiratory events in patients, especially toddlers. Key Words: Capnography; Conscious Sedation; Hypoventilation; Ketamine; Pediatrics