Severe Respiratory Events Research Articles

Pro-Con Debate: Universal Versus Selective Continuous Monitoring of Postoperative Patients.

In this Pro-Con commentary article, we discuss use of continuous physiologic monitoring for clinical deterioration, specifically respiratory depression in the postoperative population. The Pro position advocates for 24/7 continuous surveillance monitoring of all patients starting in the postanesthesia care unit until discharge from the hospital. The strongest arguments for universal monitoring relate to inadequate assessment and algorithms for patient risk. We argue that the need for hospitalization in and of itself is a sufficient predictor of an individual's risk for unexpected respiratory deterioration. In addition, general care units carry the added risk that even the most severe respiratory events will not be recognized in a timely fashion, largely due to higher patient to nurse staffing ratios and limited intermittent vital signs assessments (e.g., every 4 hours). Continuous monitoring configured properly using a "surveillance model" can adequately detect patients' respiratory deterioration while minimizing alarm fatigue and the costs of the surveillance systems. The Con position advocates for a mixed approach of time-limited continuous pulse oximetry monitoring for all patients receiving opioids, with additional remote pulse oximetry monitoring for patients identified as having a high risk of respiratory depression. Alarm fatigue, clinical resource limitations, and cost are the strongest arguments for selective monitoring, which is a more targeted approach. The proponents of the con position acknowledge that postoperative respiratory monitoring is certainly indicated for all patients, but not all patients need the same level of monitoring. The analysis and discussion of each point of view describes who, when, where, and how continuous monitoring should be implemented. Consideration of various system-level factors are addressed, including clinical resource availability, alarm design, system costs, patient and staff acceptance, risk-assessment algorithms, and respiratory event detection. Literature is reviewed, findings are described, and recommendations for design of monitoring systems and implementation of monitoring are described for the pro and con positions.

Preoperative Predictors of Severe Respiratory Events After Tonsillectomy: Consideration for Pediatric Intensive Care Admission.

Few data are available to guide postadenotonsillectomy (AT) pediatric intensive care (PICU) admission. The aim of this study of children with a preoperative polysomnogram (PSG) was to assess whether preoperative information may predict severe respiratory events (SRE) after AT. Retrospective cohort study. Single tertiary center. Children aged 6 months to 17 years who underwent AT with preoperative polysomnography (2012-2018) were identified by billing codes. Data were extracted from medical records. SRE were defined as any 1 or more of desaturations <80% requiring intervention; newly initiated positive airway pressure; postoperative intubation; pneumonia/pneumonitis; respiratory code, cardiac arrest, or death. We hypothesized that SRE would be associated with age <24 months, major medical comorbidity, obesity (>95th percentile), apnea-hypopnea index (AHI) ≥ 30, and O2 nadir <70% on PSG. Analysis was performed with multivariable logistic regression. Of 1774 subjects, 28 (1.7%) experienced SRE. Compared to those without, children with SRE were on average younger (3 vs5 years, p < .01) with a greater probability of medical comorbidities (59% vs 18%, p < .001). After adjustment for sex, black race, obesity, and age <24 months, children with major medical comorbidity were more likely than other children to have SRE (odds ratio [OR]: 14.2; 95% confidence interval [CI]: [5.7, 35.2]), as were children with AHI ≥ 30 (OR: 7.7 [3.0, 19.9]), or O2 nadir <70% (OR 6.1 [2.1, 17.9]). Age, obesity, sex, and black race did not independently predict SRE. PICU admission may be most prudent for children with complex medical co-morbidities, high AHI (>30), and/or low O2 nadir (<70%).

ANTIPSYCHOTIC USE AND RISK OF ACUTE RESPIRATORY FAILURE IN PATIENTS WITH COPD

ANTIPSYCHOTIC USE AND RISK OF ACUTE RESPIRATORY FAILURE IN PATIENTS WITH COPD

Reducing the time to successful intravenous cannulation in anaesthetised children with poor vein visibility using a near-infrared device: A randomised multicentre trial.

During inhalational induction of anaesthesia for children, severe respiratory events can occur but can be rapidly treated once intravenous access is in place. Reducing the time to successful cannulation during inhalational induction for children with poor vein visibility would improve safety. To study the effectiveness of a near-infrared (NIR) vascular imaging device (Veinviewer) to facilitate intravenous cannulation. A prospective, multicentre, randomised, open clinical trial. The operating rooms of three paediatric hospitals in Paris, France, from 1 October 2012 to 31 March 2016. Children up to the age of 7 years, with poor vein visibility requiring general anaesthesia. Inhalational anaesthesia was initiated and intravenous cannulation was performed with the standard approach or with the Veinviewer Vision. The primary outcome was the time to successful intravenous cannulation. A secondary outcome was the proportion of successful first attempts. The mean time to successful intravenous cannulation was 200 (95% CI, 143 to 295) seconds in the Veinviewer and 252 (95% CI, 194 to 328) seconds for the control group: hazard ratio 1.28 (1.02 to 1.60) (P = 0.03). The adjusted hazard ratio for known predictive factors was 1.25 (0.99 to 1.56) (P = 0.06). Success at the first attempt was 64.6% (102/158) in the 'Veinviewer' group vs. 55.6% (85/153) in the 'control' group (P = 0.10). The Veinviewer has limited value in reducing the time to successful intravenous cannulation during inhalational anaesthesia for young children with poor vein visibility. However, there is a strong trend to reducing the delay in some cases and, given its absence of side effects, it could be part of a rescue option for a difficult venous-access strategy. NCT01685866 (http://www.clinicaltrials.gov).

Acute stroke and TIA patients have specific polygraphic features of obstructive sleep apnea

PurposeObstructive sleep apnea (OSA) is associated with increased risk for stroke, which is known to further impair respiratory functions. However, it is unknown whether the type and severity of respiratory events are linked to stroke or transient ischemic attack (TIA). Thus, we investigate whether the characteristics of individual respiratory events differ between patients experiencing TIA or acute ischemic stroke and matched patients with clinically suspected sleep-disordered breathing.MethodsPolygraphic data of 77 in-patients with acute ischemic stroke (n = 49) or TIA (n = 28) were compared to age, gender, and BMI-matched patients with suspected sleep-disordered breathing and no cerebrovascular disease. Along with conventional diagnostic parameters (e.g., apnea-hypopnea index), durations and severities of individual apneas, hypopneas and desaturations were compared between the groups separately for ischemic stroke and TIA patients.ResultsStroke and TIA patients had significantly shorter apneas and hypopneas (p < 0.001) compared to matched reference patients. Furthermore, stroke patients had more central apnea events (p = 0.007) and a trend for higher apnea/hypopnea number ratios (p = 0.091). The prevalence of OSA (apnea-hypopnea index ≥ 5) was 90% in acute stroke patients and 79% in transient ischemic attack patients.ConclusionStroke patients had different characteristics of respiratory events, i.e., their polygraphic phenotype of OSA differs compared to matched reference patients. The observed differences in polygraphic features might indicate that stroke and TIA patients suffer from OSA phenotype recently associated with increased cardiovascular mortality. Therefore, optimal diagnostics and treatment require routine OSA screening in patients with acute cerebrovascular disease, even without previous suspicion of OSA.

Neuropsychological correlates of obstructive sleep apnea severity in patients with epilepsy.

Obstructive sleep apnea affects up to 30% of patients with epilepsy. As obstructive sleep apnea represents a clinical risk factor for cognitive deficits, its occurrence in epilepsy patients may exacerbate cognitive deficits associated with this condition. However, the cognitive burden of obstructive sleep apnea in epilepsy remains poorly understood. We conducted a retrospective record review of adults with epilepsy who underwent a polysomnography and a neuropsychological assessment at Brigham and Women's Hospital. We examined the relationship between obstructive sleep apnea severity and cognitive functioning, particularly attention/executive functions, memory, and processing speed in untreated obstructive sleep apnea patients with epilepsy. Twenty patients with epilepsy and mild-to-severe obstructive sleep apnea were included in the analyses. We found significant positive correlations between the oxygen saturation levels during rapid-eye-movement sleep and attention/executive tests (p<0.05), as well as time spent with saturation levels ≤90% and executive functioning (p=0.008). Similarly, worse verbal memory performances were associated with lower oxygen levels (p=0.003). In addition, more severe respiratory events during rapid-eye-movement sleep were associated with worse performances on attention tests (p=0.03). Our findings indicate that more severe obstructive sleep apnea-related hypoxemia during sleep is associated with poorer cognitive performances on tests that assess attention/executive functions and verbal memory in patients with epilepsy. Overall, these results are consistent with the sleep apnea literature, and suggest that patients with epilepsy are also vulnerable to the effects of obstructive sleep apnea. Future prospective studies will help in determining whether treatment of obstructive sleep apnea may help improve cognitive functioning in patients with epilepsy.

The influence of socio-economic status on the severity of obstructive sleep apnea: a cross-sectional observational study.

Objective There is limited evidence about the effect of socio-economic status (SES) on the severity of obstructive sleep apnea (OSA). We aimed to investigate this relationship in a referral population in Greece, with regards to other established risk factors. Methods: We used a retrospective cross-sectional design to assess socio-economic status based on occupational activity in a sample of 282 OSA patients diagnosed in a public hospital sleep laboratory during one-year period. Demographic, anthropometric and social characteristics, as well as the Epworth sleepiness scale (ESS) scores and apnea-hypopnea indexes (AHI) of subjects in each socio-economic class were recorded and statistically significant differences were explored in univariate and multiple regression analysis. Results: 99 (35.1%) of the subjects were categorized in the upper, 70 (24.8%) in the intermediate and 113 (40.1%) in the working class. Subjects of the intermediate class had significantly larger neck circumference than those of the upper class (p=0.022). Neither class differed significantly in terms of ESS score and intermediate class had a trend for higher AHI than upper class (p=0.075 in univariate and p=0.082 in multivariate analysis). Age (p=0.020) and occasional alcohol consumption (p=0.022) were independent negative and neck circumference (p<0.001) positive correlates of the variance in ESS score, while body mass index (p=0.004), neck circumference (p<0.001), being married (p=0.014) and current smoker (p=0.025) were independent positive correlates of the variance in AHI. Discussion: SES has a minor effect on OSA severity that is only partially accounted for by other known risk factors. Neck circumference was found to be the most useful predictor of both subjective daytime sleepiness and severity of respiratory events during sleep.

Incidence of adverse events in paediatric procedural sedation in the emergency department: a systematic review and meta-analysis

Objective and designWe conducted a systematic review and meta-analysis to evaluate the incidence of adverse events in the emergency department (ED) during procedural sedation in the paediatric population. Randomised controlled...

Amount of weight loss or gain influences the severity of respiratory events in sleep apnea.

Severity of obstructive sleep apnea (OSA) is estimated based on respiratory events per hour [i.e., apnea-hypopnea index (AHI)]. The aim of this study was to investigate effects of weight change on the severity of respiratory events. Respiratory event severity, including duration and morphology, was estimated by determining parameters quantifying obstruction and desaturation event lengths and areas, respectively. Respiratory events of 54 OSA patients treated with dietary intervention were evaluated at baseline and after 5-year follow-up in subgroups with different levels of weight change. AHI, oxygen desaturation index (ODI) and obstruction event severities decreased during weight loss. In lower level weight loss, the decrease was milder in obstruction severity than in AHI and ODI, indicating that the decrease in the number of events is more focused on less severe events. In weight gain groups, parameters incorporating obstruction event severity, AHI and ODI increased, although increase was greater in parameters incorporating obstruction event severity. The number and severity of respiratory events were modulated differently by the level of weight change. AHI misses this change in the severity of respiratory events. Therefore, parameters incorporating information on the respiratory event severities may bring additional information on the health effects obtained with dietary treatment of OSA.

T-I-066 RELATIONSHIP BETWEEN SYMPATHETIC AND CORTICAL REACTIVITY IN RESPONSE TO RESPIRATORY EVENTS DURING SLEEP

Introduction and Objectives: Several studies have suggested a tight and reciprocal relationship between autonomic and cortical reactivity to different types of stimuli during sleep, with concomitant cortical arousal and sympathetic activation after the stimulus and an increase in sympathetic basal activity when the stimulus gives rise to an arousal. However, this relationship remains unclear in case of respiratory events. Thus, we studied autonomic reactivity after respiratory events according to sleep stages, type of respiratory events, presence of cortical arousal (CA) and autonomic activity during respiratory events. Materials and Methods: Fourteen untreated patients with obstructive sleep apneas/hypopneas syndrome underwent laboratory polysomnographic recordings. RR intervals (RR) and spectral analysis of RR by wavelet transform were used to study sympathetic (LFWV and LFWV/HFWV ratio) and parasympathetic (HFWV) activities before and after the end of respiratory events. These RR variability indexes were compared according to sleep stages (stage 2, slow wave sleep and paradoxical sleep), to the severity of respiratory events (hypopnea with or without oxygen desaturation, and obstructive apnea) and presence cortical arousal. The possible relationship between RR variability indexes before the end of respiratory events and the occurrence of subsequent CA were studied by adjusted multivariate statistic analysis. Results: After respiratory events, RR (p<0.001) and HFWV (p=0.033) decrease whereas LFWV (p=0.006) and LFWV/HFWV ratio (p=0.001) increase, without any statistical difference according to sleep stages and severity of respiratory events. Decrease in RR (p=0.001) and increase in LFWV/HFWV ratio (p=0.008) were significantly higher when respiratory events gave rise to CA. Multivariate analysis showed that high level of LFWV and LFWV/HFWV ratio during respiratory events were related to CA (p<0.001). Conclusion: These results suggest that the sympathetic cardiac reactivity to respiratory events is modulated by arousal process rather than by sleep stages or severity of respiratory events, and reciprocally, sympathetic dominance during respiratory events could facilitate the occurrence of subsequent cortical arousal.

Postoperative adverse respiratory events in preschool patients with inhaled foreign bodies: an analysis of 505 cases

To identify the risk factors associated with postoperative adverse respiratory events in preschool-aged children with inhaled foreign bodies (FBs) undergoing rigid bronchoscopy. Foreign bodies aspiration is the most common cause of admission in pediatric emergency in otolaryngology service. Performance of rigid bronchoscopy is the standard treatment for removal of FBs in children. In some cases, severe respiratory events (complete laryngospasm and pneumothorax) may cause anesthesia-related morbidity and mortality. However, the association between patient-related factors and postoperative complications in preschool-aged children with inhaled FBs undergoing rigid bronchoscopy is unclear. We carried out a large prospective, single-institution review of anesthesia for 505 American Society of Anesthesiologists I-III preschool children aged ≤7 with inhaled FBs undergoing rigid bronchoscopy. Patients with postoperative adverse respiratory events were classified into two groups: the minor events group [hemorrhage, minor desaturation, and partial laryngospasm (wheezing, stridor, and dyspnea)) and the major events group (complete laryngospasm, including major desaturation, and pneumothorax). The incidence of postoperative adverse respiratory events was 9.5% in preschool-aged children with inhaled FBs undergoing rigid bronchoscopy. Preoperative respiratory impairment was associated with an increased risk for the complicate (P < 0.01). Pneumothorax occurred in 4 (0.8%) patients. There was 1 (0.2%) death from severe respiratory-related complications. Preoperative respiratory impairment may develop the patients with FBs into postoperative adverse respiratory events.