Health-related quality of life in patients with obstructive sleep apnoea and chronic obstructive pulmonary disease (overlap syndrome).

The association of obstructive sleep apnoea (OSA) and chronic obstructive pulmonary disease (COPD) is not rare as COPD and OSA are both frequent diseases. The aim of this study was to determine the effect of OSA on quality of life (QOL) in patients with overlap syndrome (OVS). Thirty subjects with OVS and 15 control subjects participated. The St George's Respiratory Questionnaire (SGRQ) was used to determine QOL. The control group included subjects with COPD and no evidence of OSA by overnight polysomnography. All subjects were habitual snorers with normal Epworth Sleepiness Scale scores. Significant differences were found between the groups for the total score and each of the three components of the SGRQ suggesting worse QOL in OVS patients (symptoms 54.9 +/- 18.9 vs. 38.2 +/- 19.3, p = 0.008; activity 59.2 +/- 16.2 vs. 44.4 +/- 11.3, p = 0.003; impacts 35.2 +/- 23 vs. 20.8 +/- 8.7, p = 0.025 and total 45.7 +/- 17.7 vs. 30.9 +/- 8.7, p = 0.004 in OVS patients and control group, respectively). Obstructive sleep apnoea has a major impact on QOL in patients with OVS and can exist in COPD patients with habitual snoring even in the absence of daytime sleepiness. Further studies are needed to determine the impact of OSA treatment on QOL and morbidity in this population.

Incremental risk of obstructive sleep apnea on cardiac surgical outcomes.

AIM: Obstructive sleep apnea (OSA) is not generally acknowledged as a perioperative risk factor. High incidence of Sleep disordered breathing has been noticed in patients with cardiovascular disease. The Sleep Heart Health Research Study Group found Apnea-Hypopnea indices (AHI) as modest as 1-10 to be associated with cardiovascular disease manifestations. Given the lack of data we chose to study the incremental risk of OSA in patients undergoing cardiac surgery. METHODS: We looked at 25 587 patients who underwent cardiac surgery at the Cleveland Clinic. Of these, 37 patients were also identified on the Cleveland Clinic Sleep center database as having OSA. Each of these 37 cases were propensity matched for multiple covariates with 5 controls within a distance of 0.001 units. An assumption was made that if the surgery was performed within two years of the diagnosis of OSA, the patient had OSA at the time of the surgery. RESULTS: Higher incidence of encephalopathy (p=0.008), postoperative infection (0.028) and increased ICU length of stay (p=0.031) were noted in the group with OSA after cardiac surgery. The difference in the rates of infection was mostly accounted for by the presence of mediastinitis (8.1% vs 1.6%). Differences in the rates of reintubation, tube time, and overall postoperative morbidity were not statistically significant. CONCLUSIONS: | Increased risk for postoperative complications is suggested in patients with OSA undergoing cardiac surgery. This risk is underestimated on account of lack of awareness about the incidence of OSA in the general population and the cardiovascular population in particular, difficulties in clinical suspicion and diagnosis and limited use of polysomnography.

Nocturnal hypoxemia is common in primary pulmonary hypertension.

STUDY OBJECTIVE: Unsuspected sleep-related respiratory events are common in patients with severe pulmonary disease. Sleep in patients with primary pulmonary hypertension (PPH) has not been studied (to our knowledge). The purpose of this study was to measure the prevalence of respiratory disturbances and nocturnal hypoxemia during the sleep of patients with PPH. SETTING: Tertiary-care referral hospital. DESIGN: Retrospective review. PATIENTS: Thirteen patients with PPH. MEASUREMENTS: All patients underwent a single-night comprehensive polysomnogram study. Patients who spent > 10% of the total sleep time with oxygen saturation by pulse oximetry (SpO(2)) at < 90% or who needed oxygen to maintain their SpO(2) level at > 90% were classified as nocturnal desaturators. Analysis was performed to determine which clinical variables (ie, demographics, body mass index, spirometry, diffusion capacity, right heart catheterization pressures, 6-min walk test, arterial blood gas levels, resting and walking SpO(2) levels, and polysomnogram variables) would predict nocturnal desaturation. Statistical significance was considered when p values were < 0.05. RESULTS: Of the 13 patients in the study, 10 (77%) were nocturnal desaturators. All patients had normal apnea indexes, but two had mild elevations of the hypopnea index (< 15 episodes per hour). Nocturnal desaturations occurred independently of apneas or hypopneas. Six patients who did not have O(2) titration during sleep spent > 25% of sleep time with SpO(2) < 90%. The mean (+/- SD) variables that were significantly different between desaturators (10 patients) and nondesaturators (3 patients) were FEV(1) (70.1 +/- 9.1% predicted vs 98.1 +/- 15.1% predicted, respectively; p = 0.002), resting PaO(2) (61.8 +/- 16.1 vs 90.3 +/- 2.3 mm Hg, respectively; p = 0.001), alveolar-arterial oxygen pressure difference (P[A-a]O(2)) (40.5 +/- 20.5 vs 12.2 +/- 7.2 mm Hg, respectively; p = 0.048), resting SpO(2) (91.6 +/- 5.4% vs 98.7 +/- 2.3%, respectively; p = 0.038), and walking SpO(2) (83.8 +/- 9.3% vs 95.3 +/- 1.2%, respectively; p = 0.002). The mean hemoglobin level was higher in the group of nocturnal desaturators than in the group of nondesaturators (10.43 +/- 0.31 vs 13.95 +/- 0.98 g/dL, respectively; p < 0.0001). CONCLUSION: Seventy-seven percent of patients with PPH have significant nocturnal hypoxemia that is unrelated to apneas and hypopneas. Nocturnal desaturation occurs more frequently in patients with higher P(A-a)O(2) values and lower FEV(1) values, resting arterial PaO(2) and SpO(2) values, and walking SpO(2) values.

An arrhythmia detector and heart rate estimator for overnight polysomnography studies.

We present an algorithm for automatic on-line analysis of the electrocardiography (ECG) channel acquired during overnight polysomnography (PSG) studies. The system is independent of ECG morphology, requires no manual initialization, and operates automatically throughout the night. It highlights likely occurrences of arrhythmias and intervals of bad signal quality while outputting a continual estimate of heart rate. Algorithm performance is validated against standard ECG databases and PSG data. Results demonstrate a minimal false negative rate and a low false positive rate for arrhythmia detection, and robustness over a wide range of noise contamination.

The polysomnogram assay: a method to represent the overnight polysomnogram in a condensed format.

We present the polysomnogram assay (PSGA), a new representation format for the polysomnogram (PSG), designed to assist in the interpretation of overnight PSG studies. The technique condenses the PSG record by a factor of 30 while preserving the ability to portray PSG features of diagnostic relevance, including sleep architecture, arousals, movement, leg jerks, cyclic alternating pattern, and increased breathing effort. The PSGA patterns associated with these events are described and illustrated by examples. The new format considerably reduces the effort required to evaluate sleep quality and continuity, making it more practicable for the polysomnographer to interpret the entire overnight PSG study. The compressed time scale also facilitates analysis of relatively long PSG episodes and allows assessment of signal activity surrounding critical PSG events. The PSGA appears capable of improving identification of arousals, leg jerks, and upper airway resistance, and may be especially amenable for automatic analysis of PSG data.

Albuterol delivered by metered-dose inhaler (MDI), MDI with spacer, and Rotahaler device--a comparison of efficacy and safety.

A randomized double-blind, triple crossover study was conducted on 20 asthmatic patients (7 males and 13 females; age 40.9 +/- 14.2 Caucasians, 11 blacks, and 1 oriental. Criteria for admission included FEV1 < or = 80% of predicted when inhaled beta-agonists were witheld for at least 6 hrs and oral beta-agonists for 12 hr, in addition to at least 15% increase in FEV1, 15 min after treatment with albuterol with spacer delivery. Each of the study patients were tested on each of 3 separate days (within the same week) at baseline, 15, 30, 60, 120, 180, 240, 300, and 360 min post treatment. On each day albuterol was delivered by one of the 3 delivery devices and the other two methods delivered placebo. Albuterol was administered at the maximum recommended dosages of two puffs for MDI. Two puffs for MDI with spacer, and two capsules for Rotahaler. Spirometry, blood pressure and heart rate were measured at each testing interval. The mean percentage in FEV1 was higher in Rotahaler group compared to MDI with spacer (p < 0.001) and no significant difference in FEV1 was found between Rotahaler and MDI alone (p = 0.31). No significant changes in heart rate or blood pressure were associated with albuterol delivery by any of the three methods. Albuterol inhaled as a microfine powder was more effective than the same drug delivered as an aerosol by either MDI or MDI with spacer.

Transudative malignant pleural effusions: prevalence and mechanisms.

BACKGROUND: Malignant pleural effusions are classically exudative, though occasionally they can be transudative. We attempted to determine the prevalence of transudative malignant pleural effusions and to describe their clinical and radiographic characteristics. METHODS: We studied the medical records of 215 patients with malignant pleural effusion, which contained complete data on pleural fluid analysis for 171 of them. RESULTS: Eight cases of transudative malignant effusion were found. Seven of these eight patients had a concomitant disorder known to cause transudative pleural effusion. One patient had fluid overload due to renal failure, and another had been admitted earlier with congestive heart failure. Two patients had definite evidence of deep venous thrombosis, allowing us to postulate pulmonary embolism as a factor contributing to transudation. Three patients had CT evidence of superior vena cava obstruction. Only one patient had no known associations with causes of transudative effusion. CONCLUSION: Malignant pleural effusions were transudative in 5% of our patients. In all except one patient, some evidence suggested the concomitant presence of a transudative state.

Aortopulmonary fistula in an infected Dacron graft for coarctation of the aorta: an uncommon cause of hemoptysis.

Hemoptysis secondary to an aortobronchial fistula is rare and uniformly fatal when left untreated. The authors describe a case of massive hemoptysis caused by an aortopulmonary fistula in an infected Dacron graft used successfully to repair a coarctation of the aorta.

Clinical management of asthma in the 1990s. Current therapy and new directions.

Asthma is a serious global health problem affecting nearly 100 million people worldwide. Its rising prevalence and associated morbidity and mortality are of increasing concern. Traditionally, symptomatic control of bronchoconstriction with beta 2 agonists and theophylline has been the mainstay of therapy. However, during recent years, inflammation has been recognised as the predominant cause of reversible airway obstruction and airway hyperreactivity. As a result, the emphasis in treatment has shifted to the early use of inhaled corticosteroids to control airway inflammation. beta 2 agonists are best used on an as-needed basis for the relief of acute bronchoconstriction and for the prevention of exercise-induced asthma. Sustained release theophylline or an inhaled long-acting beta 2 agonist may effectively control nocturnal symptoms. Preliminary studies involving agents active in the 5-lipoxygenase pathway as preventive therapy are encouraging. Further studies are needed to define their role in the management of asthma.

Dynamic pharyngoscopy in predicting outcome of uvulopalatopharyngoplasty for moderate and severe obstructive sleep apnea.

STUDY OBJECTIVE: We sought to determine whether preoperative fiberoptic pharyngoscopy (FOP) with Müller's maneuver (dynamic FOP) could be used to establish a subgroup of obstructive sleep apnea (OSA) patients with better outcome after uvulopalatopharyngoplasty (UPPP). DESIGN: Retrospective review of an observational cohort. SETTING: Tertiary care referral center. PATIENTS: Twenty-nine patients who underwent UPPP and nasopharyngeal surgery by one surgeon. INTERVENTION: The patients were divided into two groups based on the findings of preoperative dynamic FOP: group 1 (11 patients) had collapse of the velopharynx and the base of the tongue-epiglottis-hypopharynx (TEH) complex and group 2 (18 patients) had velopharyngeal collapse only. MEASUREMENTS AND RESULTS: Surgical success was defined using a conventional definition (> 50% reduction in the apnea-plus-hypopnea index [OAHI]), and a criterion for cure (> 90% reduction in OAHI and postoperative OAHI < 15). Both groups had a significant improvement in their OAHI. The success rate was significantly higher in patients with velopharyngeal collapse only compared with patients with additional collapse of the TEH complex (78 vs 36% with the conventional definition, and 50 vs 9% using the definition for cure, respectively). Predictive value of dynamic FOP in predicting cure failure when collapse of the TEH complex was present was 91%. CONCLUSIONS: Dynamic FOP may help establish a subgroup of OSA patients with greater likelihood of successful UPPP. The high negative predictive value of dynamic FOP when a criterion for cure is used suggests that this maneuver could best be used to exclude patients with TEH complex collapse from UPPP.

Obstructive sleep apnea. Warding off the sometimes dire consequences.

Obstructive sleep apnea (occlusion of the upper airway despite continued respiratory muscle activity) is accompanied by increased morbidity and mortality from cardiovascular and cerebrovascular disease. Daytime sleepiness due to the disorder may also be a factor in a higher incidence of automobile accidents in these patients. An overnight polysomnogram is used to confirm the diagnosis and assess severity of physiologic disturbances. Initially, simple measures, such as avoidance of alcohol and sedatives before bedtime and sleeping on the side rather than the back, may be tried. Nasal continuous positive airway pressure is considered first-line therapy, and compliance can be improved by education and counseling of the patient. Uvulopalatopharyngoplasty is beneficial in only 50% of patients. Tracheostomy gives the most consistent long-term benefit but is accompanied by significant emotional morbidity.

Changing strategies in the management of asthma.

Mortality from asthma is apparently on the rise and, in some cases, may be due to the type and amount of medication used by the patient. As a result, the role of some commonly prescribed agents has changed in recent years. In this article, the authors review modifications in the use of currently available drugs, discuss new applications of drugs not traditionally used for asthma, and examine the rationale behind the development of entirely new classes of drugs.

Women and lung cancer: a comparison of active and passive smokers with nonexposed nonsmokers.

Prior to the 1920s, lung cancer was a rare disease. However, the current increase in lung cancer appears to parallel the increase in smoking for both men and women with a 30- to 50-year delay. National lung cancer deaths continue to rise, with over 168,000 total deaths estimated in 1992. Women are now showing higher percentage increases in lung cancer than men from active smoking. The data from the Erie County Study on Smoking and Health (ECSSH), a population study, were used to measure the effects of both active and passive smoking on women's lung cancer mortality. The three major categories of exposure (no known or minimal exposure, passive smoking exposed, and active smoking) were used in the analyses. The results from the population data in Erie County, PA, were based on 528 nonexposed nonsmoking women, 3138 exposed nonsmoking women, and 1747 smoking women. Deaths due to lung cancer as a percentage of total deaths excluding traumatic deaths were 0.2% for the nonexposed nonsmoking women, 0.9% for the exposed nonsmoking women, and 8.0% for women who smoked. The data showed that women smokers died of lung cancer at a rate 9 times greater than exposed nonsmokers and 42 times greater than nonexposed nonsmokers.

Giant esophageal varices. An unusual cause of a posterior mediastinal mass.

Esophageal pathology rarely presents as posterior mediastinal abnormalities on chest roentgenograms, with the most common being hiatal hernia. We describe a patient with giant esophageal varices manifesting as a retrocardiac, posterior mediastinal mass.

A physician's guide to smoking cessation.

Claims of the effectiveness of smoking cessation services and products are often misleading. It is important that physicians be well informed in order to make appropriate recommendations to their patients who smoke. In this article smoking cessation products and programs are critically evaluated and issues such as cure rates and validation of self-reported abstinence are discussed. Many commercial products are available to aid in cessation, although none has been proven effective. With the exception of nicotine polacrilex gum and transdermal patches in conjunction with a multicomponent clinic, medications are generally ineffective. Smoking cessation programs range from the provision of self-help materials to multisession groups and clinics. Multicomponent, behavioral-based group programs have been the most successful. Physicians should raise the issue of smoking cessation as frequently as possible with smokers and should recommend the use of smoking cessation products and services as appropriate. Referrals should be made to programs that base their success rates on scientifically accepted standards, including a 1-year follow-up, inclusion of dropouts and nonrespondents in calculating outcome, and biochemical validation of self-reported abstinence. Reports of success rates of 80% to 95% at the end of a 1-year program should be viewed with skepticism. Ideally, whether working independently or through referral, the physician should actively promote smoking cessation for all patients who smoke.

Massive air embolism complicating Nd-YAG laser endobronchial photoresection.

A 63 year old male underwent 6,900 rads of external radiation for a squamous cell carcinoma of the left main bronchus. Recurrence of the tumor 8 months later was treated with 6,618 joules and patency of the left main bronchus was restored. Four months later, he developed complete atelectasis of the left lung requiring repeat laser. During the procedure he became hypotensive, bradycardic, and hypoxic due to a tension pneumothorax. Although treated promptly with thoracostomy tube drainage, the patient never awakened. CT scan of the brain demonstrated anoxic encephalopathy with air present in the right frontal lobe. Brain death was confirmed by an EEG and cerebral angiogram. Air embolism has been reported in conjunction with diagnostic procedures including therapeutic pneumothorax for tuberculosis, transthoracic needle biopsy of the lung, and positive pressure ventilation with or without pneumothorax. The only reported case of air embolism associated with laser was a small middle cerebral artery cerebro-vascular accident which was self limited. Its mechanism is unclear, but it is suspected to be due to a communication between a pulmonary vein and the atmosphere. A greater volume of air will enter the damaged vessel in the setting of positive pressure ventilation and/or a tension pneumothorax. When neurologic manifestations are present, hyperbaric oxygen therapy is the treatment of choice. Prompt institution in hemodynamically stable patients can minimize neurologic sequelae.

Quantitation of abnormal 67Ga uptake in pulmonary interstitial vascular disease--a new test to detect diffuse lung disease.

Gallium 67 has been used as a modality to diagnose and follow the clinical course of diseases such as tumors, infections, inflammatory disorders, and interstitial lung disease. It has been appreciated, however, that mild to moderate changes in scan activity, when these disorders are followed over time, are less than optimal. SPECT (single-photon emission computed tomography) scanning is a new technique designed to obviate this problem. SPECT scanning utilizes computer acquisition to provide three-dimensional scanning and the additional benefit of colorization to aid in discerning differences of uptake. SPECT scanning was performed on 22 patients with interstitial lung disease of various etiologies. Additionally, 7 patients had follow-up SPECT scanning to determine their response to treatment. Two patients are presented as examples.