The relationship of sedation to deliberate self-extubation.

STUDY OBJECTIVES: To evaluate the relationship between sedative therapy and self-extubation in a large medical-surgical intensive care unit (ICU). DESIGN: Retrospective, case-controlled study. SETTING: Large teaching hospital. PATIENTS: All adult patients who underwent unplanned self-extubation during a 12-month period (n = 50). Each patient was matched to two control patients who did not self-extubate based on age, gender, dates in hospital and diagnosis. INTERVENTIONS: none. MEASUREMENTS: Data collected included time to self extubation, dosages and types of benzodiazepines, opioid analgesics, antipsychotics, and hypnotics. Data on the degree of agitation as assessed by nursing staff also were obtained. MAIN RESULTS: When compared to controls, patients in the self-extubation group were more likely to have received benzodiazepines (59% vs. 35%; p < 0.05), but equally likely to have received opioids and/or paralytic drugs. Patients who self-extubated were twice as likely as controls to be agitated (54% vs. 22%; p < 0.05). Use of benzodiazepines was more common in agitated patients than in nonagitated patients (62% vs. 35%; p < 0.02). Among nonagitated patients who self-extubated, increased use of benzodiazepines (57% vs. 29%; p < 0.05) was noted when compared to nonagitated controls. CONCLUSIONS: In intubated ICU patients, benzodiazepines may not consistently treat agitation effectively or prevent self-extubation. Such an effect may be due to paradoxical excitation, disorientation during long-term administration, or differences in drug administration between ICU and operating room (OR) environments.

Sleep latency and duration estimates among sleep disorder patients: variability as a function of sleep disorder diagnosis, sleep history, and psychological characteristics.

STUDY OBJECTIVES: Insomnia patients often report greater sleep disturbance than found via polysomnography; yet the specific patient factors related to such sleep time misperceptions are poorly understood. We sought to characterize the extent to which a diverse group of patients complaining of insomnia (n=104) misperceive overnight total sleep time and sleep latency, and to identify patient factors associated with these variations. DESIGN: Cross-sectional. SETTING: University based sleep disorders center. PATIENTS: Sleep disorder groups consisted of patients with psychophysiological insomnia (n=19), sleep state misperception (n=8), insomnia with depressive disorder (n=11), insomnia secondary to Axis I psychiatric disorder other than depression (n=21), periodic limb movement disorder (n=24), and obstructive sleep apnea (n=21). MEASUREMENT AND RESULTS: Patients completed a sleep history questionnaire and the MMPI, underwent overnight diagnostic polysomnographic assessment, and then estimated their total sleep time and sleep latency the subsequent morning. On average, patients overestimated sleep latency, but were equally likely to underestimate vs. overestimate total sleep time. Sleep time misperception was associated with longer periods of wakefulness following sleep onset, greater self-perceived sleep impairment, as well as several psychological dimensions. CONCLUSIONS: Patient factors, including sleep quality, perceptions of habitual sleep time, and current psychopathology, potentially influence sleep time estimation. Whereas psychological factors may lead to exaggeration of sleep disturbance among some patients, sleep quality itself may also influence the congruence between subjective and objective indices of sleep.

Evaluating the outcome of two teaching methods of breath actuated inhaler in an inner city asthma clinic.

OBJECTIVES: Our objective was to compare two different teaching methods used to educate patients in the use of a breath actuated inhaler (BAI) and to assess the impact of its continued use on their metered-dose inhaler (MDI) technique. DESIGN: Prospective, randomized, controlled trial. SETTING: Adult Pulmonary/Asthma clinic of Cook County Hospital, Chicago, IL. PATIENTS: Diagnosed, stable asthmatics. INTERVENTION: The patients were randomized into two groups. The experimental group received verbal instructions and demonstration on breath actuated inhaler technique while the control group received written instructions only on BAI use. The metered dose inhaler technique of both groups of patients was also evaluated. MEASURES: A checklist evaluating the key aspects of proper BAI and MDI inhalation techniques was used to assess the use of both types of inhalers at entry into the study and upon postintervention follow-up at 8 to 20 weeks. RESULTS: At baseline, 97% of patients in the experimental group and 83% of patients in the control group were initially able to demonstrate BAI inhalation technique correctly. Upon follow-up, 82% of the control group and 68% of the experimental group were able to use the BAI correctly, which was a statistically significant deterioration in the experimental group. In both of these groups, there was a statistically significant improvement in MDI technique. CONCLUSIONS: Written instructions alone may be an adequate teaching tool for proper inhalation technique of BAI. Continued BAI use appears not to impact adversely on proper MDI technique.

Differential rates of psychopathology symptoms in periodic limb movement disorder, obstructive sleep apnea, psychophysiological insomnia, and insomnia with psychiatric disorder.

STUDY OBJECTIVE: To determine patterns and relative intensity of psychopathology, as measured by the Minnesota Multiphasic Personality Inventory (MMPI), in 108 patients with either psychophysiological insomnia (PI; n=20), insomnia with psychiatric disorder (IPD; n=30), periodic limb movement disorder (PLM; n=28), or obstructive sleep apnea (OSA; n=30). DESIGN: Cross-sectional. SETTING: University sleep disorders center. MEASUREMENTS AND RESULTS: Subjects completed the MMPI prior to overnight diagnostic polysomnographic assessment followed by Multiple Sleep Latency Test (MSLT). Seventy five percent of the entire sample had at least one MMPI elevation (T>70). Groups showed significant baseline differences in age, BMI, and MSLT latency (all ps<.05). Logistic regression indicated that even after statistically controlling for these three diagnostic covariates, MMPI elevation was more likely among PLM and IPD patients than OSA or PI patients (all ps<.05). Followup pairwise comparisons indicated that this same pattern of group differences occurred for the Depression, Psychasthenia, and Schizophrenia scales (all ps<.05). CONCLUSIONS: Irrespective of age, obesity, and daytime sleepiness, patients with untreated PLM or IPD are more likely to experience clinically significant psychological difficulties than those with either OSA or PI. These differences are most likely to be manifested in terms of depressive symptoms, anxiety symptoms (tension, worry, guilt), social alienation, and diminished mental concentration. Finally, PLM may be associated with greater MMPI elevations than previously suspected, and agree with earlier clinical reports of high rates of psychiatric treatment in PLM.

MMPI correlates of sleep and respiratory disturbance in obstructive sleep apnea.

STUDY OBJECTIVE: To evaluate associations between polysomnographic variables in obstructive sleep apnea (OSA) and a variety of psychological responses (including depressive symptoms) as assessed by the Minnesota Multiphasic Personality Inventory (MMPI). DESIGN: Cross-sectional. SETTING: University sleep disorders center. PATIENTS: One-hundred seventy eight consecutive clinical OSA patients. INTERVENTIONS: Not applicable. MEASUREMENTS AND RESULTS: Patients completed the MPI prior to overnight diagnostic polysomnography. Fifty-eight percent demonstrated at least one MMPI elevation (mean = 1.8 elevations), with Depression (D) elevated for 32%, Hypochondriasis (Hs) for 30%, and Hysteria (Hy) for 21%. Thirty-eight percent demonstrated two or more elevations, with several variations of Hs-D and Hs-D-Hy configurations evident. "Conversion V" profiles were fairly rare, and a large number of miscellaneous configurations occurred once. Significant correlations were detected between several MMPI scale scores and total sleep time, the apnea-hypopnea index (AHI) during REM, and particularly arterial oxygen saturation, even when partialling out variance related to body mass index (BMI). In contract, D scores were not correlated with any polysomnographic parameters. Based upon MMPI configuration, the sample was subdivided into the following seven profile groups: Nonelevated (n = 74); Single D (n = 11); Single non-D (n = 25); Combined D plus (a) HS or HY (n = 7), (b) Hs and Hy (n = 10), or (c) other (n = 29); and Multiple non-D (n = 22). Multivariate analysis controlling for age and gender indicated higher AHI in the Single non-D, Combined D plus other, and Multiple non-D groups, compared to the Single D group. Also, there was lower average oxygen saturation in the Multiple non-D group, compared to Single D, Single non-D, and Nonelevated groups. The Combined D plus HS and/or Hy groups did not differ from each other or from other groups, even when merged. The Multiple non-D findings were unattributable to any specific scale or overall number of elevations. CONCLUSIONS: OSA patients who have core depressive symptoms (as measured by MMPI scale D) without significant psychological symptoms in other areas tend to have less severe OSA, whereas those with a diverse set of other psychological symptoms overshadowing depressive symptoms (e.g., somatic focus, emotional reactivity, family/marital problems, cognitive problems, etc.) tend to have greater AHI and lower oxygen saturation. Although it seems probable that these MMPI differences primarily reflect OSA effects, prospective research is needed to confirm this hypothesis.