DOISNORE50: a perioperative sleep questionnaire predictive of obstructive sleep apnea and postoperative medical emergency team activation. A learning health system approach to sleep questionnaire development and screening.

STUDY OBJECTIVES: Patients with obstructive sleep apnea (OSA) have a disproportionate increase in postoperative complications and medical emergency team activation (META). We previously introduced DOISNORE50 (Diseases, Observed apnea, Insomnia, Snoring, Neck circumference > 18 inches, Obesity with BMI > 32, R = are you male, Excessive daytime sleepiness, 50 = age ≥ 50) from sleep questionnaire ISNORED using features associated with increased odds of META in perioperative patients. Performance of DOISNORE50 (DOISNORE) had yet to be tested. METHODS: The performance of DOISNORE was tested along with questionnaire ISNORED and STOP-BANG questionnaires among 300 out of 392 participants without known OSA referred to the sleep lab. In study 2, the performance of DOISNORE was tested among 64,949 lives screened in perioperative assessment clinic from 2016 to 2020. RESULTS: Receiver operating characteristic curve demonstrated that best performance was achieved with responses, with area under curve of 0.801. DOISNORE's predictability of OSA risk remained stable from 2018 to 2020 with area under curve of 0.78 and a Cronbach alpha of 0.65. Patients at high risk for OSA (DOISNORE ≥ 6) were associated with an increase of META (odds ratio 1.30, 95% confidence interval 1.12-1.45). Higher relative risk was noted among patients with congestive heart failure and hypercapnia. CONCLUSIONS: DOISNORE is predictive of OSA and postoperative META. Perioperative strategies against META should consider DOISNORE questionnaire and focused screening among patients with heart failure and hypercapnia. CITATION: Namen AM, Forest D, Saha AK, et al. DOISNORE50: a perioperative sleep questionnaire predictive of obstructive sleep apnea and postoperative medical emergency team activation. A learning health system approach to sleep questionnaire development and screening. J Clin Sleep Med. 2022;18(8):1909-1919.

Reduction in medical emergency team activation among postoperative surgical patients at risk for undiagnosed obstructive sleep apnea.

STUDY OBJECTIVES: Obstructive sleep apnea (OSA) is an under-recognized condition that results in morbidity and mortality. Postoperative complications, including medical emergency team activation (META), are disproportionally increased among surgical patients at risk for OSA. A systematic approach is needed to improve provider recognition and treatment, but protocols that demonstrate improvement in META are lacking. As part of a multidisciplinary quality improvement project, DOISNORE50 (DIS), a sleep apnea questionnaire and proactive safety measure, was algorithmically applied to all perioperative patients. METHODS: Consecutive sleep screening was conducted among perioperative patients. Of the 49,567 surgical navigation center patients, 11,932 had previous diagnosis of OSA. Of the 37,572 (96%) patients screened with DIS, 25,171 (66.9%) were Low Risk (DIS < 4), 9,211 (24.5%) were At Risk (DIS ≥ 4), and 3,190 (8.5%) were High Risk (DIS ≥ 6) for OSA, respectively. High Risk patients received same-day sleep consultation. On the day of surgery, patients with Known OSA, At Risk, and High Risk for OSA received an "OSA Precaution Band." An electronic chart reminder alerted admission providers to order postoperative continuous positive airway pressure (CPAP) machine and sleep consult for patients High Risk for OSA. RESULTS: Implementation of a comprehensive program was associated with increased sleep consultation, sleep testing, and inpatient CPAP use (P < .001). For every 1,000 surgical patients screened, 30 fewer META, including rapid responses, reintubation, code blues, and code strokes, were observed. However, inpatient sleep consultation and inpatient CPAP use were not independently associated with reduced META. In the subgroup of patients hospitalized longer than 3 days, inpatient CPAP use was independently associated with reduced META. CONCLUSIONS: In this single-center, institution-wide, multidisciplinary-approach, quality improvement project, a comprehensive OSA screening process and treatment algorithm with appropriate postoperative inpatient CPAP therapy and inpatient sleep consultations was associated with increased CPAP use and reduced META. Further prospective studies are needed to assess cost, feasibility, and generalizability of these findings. CITATION: Namen AM, Forest D, Saha AK, et al. Reduction in medical emergency team activation among postoperative surgical patients at risk for undiagnosed obstructive sleep apnea. J Clin Sleep Med. 2022;18(8):1953-1965.

Preoperative Sleep Questionnaires Identify Medical Emergency Team Activation in Older Adults.

Patients with obstructive sleep apnea (OSA) have increased postoperative complications that are important for patient safety and healthcare utilization. Questionnaires help identify patients at risk for OSA; however, among older adults who preoperatively self-administered OSA questionnaires, the frequency of postoperative Medical Emergency Team Activation (META), rapid response, code blue, code stroke, is unknown. OBJECTIVES: Identify whether having OSA questionnaires completed by patients is feasible in the preoperative clinic. Determine the frequency of META among older patients at risk for OSA. DESIGN AND INTERVENTION: Cohort of prospective patients independently completed 2 OSA questionnaires in a preoperative clinic, STOP-Bang (SB) and ISNORED (IS). Observers blinded to questionnaire responses recorded incidence of META. SETTING AND PARTICIPANTS: Of the 898 consecutive patients approached in the preoperative assessment clinic and surgical navigation center, 575 (64%) consented and completed the questionnaires in <5 minutes and were included in the analysis. MEASURES: Sleep questionnaire responses and frequency of inpatient postoperative META. RESULTS: With an affirmative response to ≥3 questions on either questionnaire, 65% of patients enrolled were at risk for OSA. Of these, 3.1% sustained an META. In patients at risk for OSA, META occurred in 7.6% (SB+) and 7.2% (IS+) vs 2.5% (SB+) and 1.7% (IS+) for low risk. METAs were disproportionately higher among patients aged ≥65 years (6.3% vs 1.7%; P < .018), American Society of Anesthesiologists (ASA) physical status class ≥3, and IS+. All patients with META positively answered ≥3 of 15 components of the 2 questionnaires. CONCLUSIONS/IMPLICATIONS: Preoperative, self-administration of SB and IS questionnaires is feasible. Overall, 65% of those with affirmative responses to ≥3 questions were at risk for OSA and associated with a disproportionate number of postoperative META in older patients. Additionally, risk of OSA identified by preoperative sleep questionnaires was associated with postoperative META among older adults. Use of clinical tools and OSA questionnaires may improve preoperative identification of META in this population.

Bronchoscopy Safety in Patients With Chronic Obstructive Lung Disease.

BACKGROUND: Flexible bronchoscopy is a safe and minimally invasive diagnostic tool used by pulmonologists, but few studies have prospectively compared outcomes in patients with objectively defined obstructive lung disease to those without obstruction. METHODS: We determined whether complications in patients undergoing moderate sedation bronchoscopy differ in those without obstruction compared with chronic obstructive pulmonary disease (COPD). We prospectively followed all patients undergoing moderate sedation bronchoscopy in an inpatient or outpatient setting. RESULTS: Over 12 months, data were collected prospectively in 258 patients. A total o 151 patients had pulmonary function testing with classification of COPD according to GOLD Criteria. Sixty-seven of those patients (44%) had COPD: 6 mild (9%), 29 moderate (42%), 27 severe (41%), and 5 very severe (8%). COPD patients were more likely to receive outpatient inhaled corticosteroids and long-acting bronchodilators and anticholinergics (P<0.001) as would be clinically appropriate. Among all patients with COPD, there were 13% minor complications and 5% major complications, with no deaths. Respiratory complications occurred more often in patients with severe to very severe COPD (22%) compared with patients without COPD (6%) (P=0.018). When adjusted for age, body mass index, and use of home oxygen, this difference was still significant (P=0.045). CONCLUSION: Bronchoscopy is generally safe with few complications in most patients with COPD. Patients with objectively confirmed severe to very severe COPD had more frequent respiratory complications than patients without COPD. The risks were not prohibitively high, but should be taken into consideration for COPD patients undergoing moderate sedation flexible bronchoscopy.

Sedation for Bronchoscopy and Complications in Obese Patients.

BACKGROUND: Bronchoscopy is a safe and minimally invasive diagnostic tool, but no studies have reported prospectively on sedation and outcomes in patients with objectively defined obesity. OBJECTIVES: The purpose of the study is to determine if obese patients require more sedation or had more procedural complications during bronchoscopy under moderate sedation than non-obese patients. METHODS: We evaluated complications and sedation requirements in non-obese versus obese patients, defined by multiple criteria including body mass index (BMI), neck circumference, abdominal height, and Mallampati scores. RESULTS: Data were collected prospectively in 258 patients undergoing bronchoscopy under moderate sedation. By varying criteria, there were the following proportions of obese patients: 30% by BMI >30, 39% by neck circumference >40 cm, and 35% by abdominal height >22 cm in males and >20 cm in females. Sedative and analgesic dosing was not clinically significantly higher in obese patients than in non-obese patients. There was no difference in complications or procedural success based on obesity criteria. Hemoglobin oxygen desaturations occurred more often during bronchoscopy in patients with increasing Mallampati scores (p = 0.04), but this had no effect on bronchoscopy time or successful completion of the procedure. A subset of patients with previous polysomnogram-proven obstructive sleep apnea were more likely to have earlier termination of their procedure (15.8%) than patients with no diagnosed sleep apnea (2.3%; p = 0.002). CONCLUSION: In this prospective assessment of patients with obesity, we found neither clinically significant differences in sedation needs nor increases in complications in obese versus non-obese patients using a variety of indices of obesity.

Age at asthma onset and asthma self-management education among adults in the United States.

OBJECTIVE: Asthma self-management education improves asthma-related outcomes. We conducted this analysis to evaluate variation in the percentages of adults with active asthma reporting components of asthma self-management education by age at asthma onset. METHODS: Data from 2011 to 2012 Asthma Call-back Surveys were used to estimate percentages of adults with active asthma reporting six components of asthma self-management education. Components of asthma self-management education include having been taught to what to do during an asthma attack and receiving an asthma action plan. Differences in the percentages of adults reporting each component and the average number of components reported across categories of age at asthma onset were estimated using linear regression, adjusted for age, education, race/ethnicity, sex, smoking status, and years since asthma onset. RESULTS: Overall, an estimated 76.4% of adults with active asthma were taught what to do during an asthma attack and 28.7% reported receiving an asthma action plan. Percentages reporting each asthma self-management education component declined with increasing age at asthma onset. Compared with the referent group of adults whose asthma onset occurred at 5-14 years of age, the percentage of adults reporting being taught what to do during an asthma attack was 10% lower among those whose asthma onset occurred at 65-93 years of age (95% CI: -18.0, -2.5) and the average number of components reported decreased monotonically across categories of age at asthma onset of 35 years and older. CONCLUSIONS: Among adults with active asthma, reports of asthma self-management education decline with increasing age at asthma onset.

Airway obstruction among Latino poultry processing workers in North Carolina.

This analysis was conducted to evaluate the prevalence of airway obstruction among Latino poultry processing workers. Data were collected from 279 poultry processing workers and 222 other manual laborers via spirometry and interviewer-administered questionnaires. Participants employed in poultry processing reported the activities they perform at work. Participants with forced expiratory volume in 1 second (FEV1) or FEV1/forced expiratory volume (FVC) below the lower limits of normal were categorized as having airway obstruction. Airway obstruction was identified in 13% of poultry processing workers and 12% of the comparison population. Among poultry processing workers, the highest prevalence of airway obstruction (21%) occurred among workers deboning chickens (prevalence ratio: 1.75; 95% confidence interval: 0.97, 3.15). These findings identify variations in the prevalence of airway obstruction across categories of work activities.

Training in and experience with endobronchial ultrasound.

BACKGROUND: Diagnosing mediastinal and hilar lymphadenopathy and staging lung cancer with endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA) are on the rise, but uncertainty surrounds the optimal number of cases needed to achieve acceptable yields. OBJECTIVES: To determine the threshold at which EBUS-TBNA reaches adequate yields among trainees and skilled bronchoscopists. METHODS: We reviewed all EBUS-TBNAs performed at our medical center since implementing the use of EBUS (n = 222). RESULTS: EBUS-TBNAs were performed in 222 patients (344 nodes). The percentage of adequate specimens sampled (diagnostic specimens or nodal tissue) rose from 66% in 2008 to 90% in 2012 (p < 0.01) and cancer yield improved from 34% in 2008 to 48% in 2012 (p < 0.01). Attending physicians who performed an average of more than 10 procedures per year had higher yields compared to those who performed fewer than 10 procedures per year (86 vs. 68%, p < 0.01). The yield of trainees also improved with every 10 procedures (79, 90 and 95%, p < 0.001) and that of attending physicians with experience (1-25 procedures: 78% yield, 26-50 procedures: 87% yield and 50+ procedures: 90% yield; p < 0.01). Among trainees, failure rates declined steadily. CONCLUSION: EBUS-TBNA yield (malignant and benign) increases with increasing experience amongst experienced bronchoscopists and trainees as early as the first 20-25 procedures. Pulmonary trainees had a rapid decline in failure rates. These findings suggest that in an academic environment a minimum of 20-25 procedures is needed to achieve acceptable yields.

The association of respiratory symptoms and indoor housing conditions among migrant farmworkers in eastern North Carolina.

Farm labor housing has been described as among the worst in the nation, oftentimes with poor and unsanitary indoor living conditions. The objective of this study was to evaluate the association between indoor environmental risk factors and respiratory health among migrant farmworker occupants (N = 352) living in employer-provided housing. A cross-sectional sample of adult Latino male farm laborers were administered a questionnaire to identify the prevalence of major respiratory symptoms. Self-reported and independent observations were made to evaluate environmental respiratory risk factors and indoor housing conditions, including but not limited to, the presence of cockroaches, rodents, pesticides, and visible signs of mold. Spirometry was performed to evaluate lung function using FEV1 (forced expiratory volume in 1 second), FVC (forced vital capacity), and FEV1 /FVC ratio. Bivariate analysis was applied to evaluate associations between respiratory symptoms and selected indoor environmental risk factors. Findings for respiratory health included prevalence of wheeze (11.4%), coughing up phlegm (17.3%), tightness of chest (16.8%), and runny or stuffy nose (34.4%). Respiratory risks identified inside the dwellings included the use of pesticides or bug sprays for cockroaches (31.5%), rat or mouse poison (19.5%), visible signs of water damage in the bathroom (22.5%), and mold in the sleeping room (11.1%). Spirometry values were normal for most occupants, although statistically significant associations were found between mold and coughing up phlegm when not having a cold (P = .0262); presence of mold and asthma (P = .0084); pesticides used in the home and tightness of chest (P = .0001); and use of tobacco and coughing up phlegm (P = .0131). Although causal inference can be difficult to establish from a cross-sectional study, findings from this study represents suggestive evidence that indoor environmental risk factors may be contributory factors for respiratory health problems among this vulnerable workgroup population.

Active asthma and the prevalence of physician-diagnosed COPD.

INTRODUCTION: Despite the considerable overlap of asthma and chronic obstructive pulmonary disease (COPD), the extent to which the two diagnoses are the manifestations of the same disease remains unresolved. We conducted these analyses to evaluate the role of active asthma in the prevalence of physician-diagnosed COPD. METHODS: From 2006 through 2010, 74,209 adults aged 18-99 years and with a history of asthma participated in the Behavioral Risk Factor Surveillance System (BRFSS) Asthma Call-back Survey and responded to interview-administered questionnaires via telephone. We used publicly available data from 71,639 (97%) participants to identify respondents with and without active manifestations of asthma and self-reported, physician-diagnosed COPD. We generated population-weighted estimates of physician-diagnosed COPD prevalence and conducted linear regression to estimate associations between active asthma status and the prevalence of COPD among current smokers, former smokers, and lifetime nonsmokers separately. RESULTS: Physician-diagnosed COPD was reported in an estimated 29% of the population with any history of asthma, including both active and inactive asthma. Age-specific prevalences of physician-diagnosed COPD were consistently higher among adults with active asthma than adults without active asthma. Compared to inactive asthma, active asthma was associated with an 8.3% [95% confidence interval (CI) 6.1, 10.5] higher prevalence of physician-diagnosed COPD among lifetime nonsmokers, a 20.6% (95% CI 18.0, 23.3) higher prevalence among former smokers, and a 26.7% (95% CI 22.5, 30.9) higher prevalence among current smokers. CONCLUSIONS: Among adults with a history of asthma, active manifestations of asthma may play an important role in the epidemiology of COPD.

Reliability in reporting asthma history and age at asthma onset.

BACKGROUND: Evaluation of the prevalence and incidence of asthma and research into its etiology often rely on self-reported information. We conducted this analysis to investigate reliability in reporting asthma history across categories of demographic and socio-economic characteristics. METHODS: We analyzed data from 3109 participants in the Coronary Artery Risk Development in Young Adults study, a longitudinal study of African-American and white adults. Responses to self-administered questionnaires completed at 15- and 20-year follow-up exams were used to evaluate agreement in reporting asthma history and age at diagnosis and assess variation in agreement across categories of demographic and health-related characteristics. RESULTS: A history of asthma was reported by 12% of participants at the 15-year exam and 11% of participants at the 20-year exam, with 97% agreement and an overall Kappa coefficient of 0.845 (95% confidence interval: 0.815-0.874). Kappa coefficients were higher among women than men and increased monotonically across categories of educational attainment. One-hundred eight participants (35%) reported exactly the same age at diagnosis at the two time points; for another 120 (39%), the difference in reported ages was ≤2 years. Age at asthma diagnosis reported at the 20-year exam was, on an average, 1 year (SD: 5.2) older than that reported at the 15-year exam. CONCLUSIONS: Five-year reliability in self-reported asthma history is high, and variation in reporting age at diagnosis is low across categories of participant characteristics. Nevertheless, agreement in responses at two times does not guarantee that self-administered questionnaires are sensitive tools for detecting a true asthma history.

Association between housing quality and individual health characteristics on sleep quality among Latino farmworkers.

Although poor sleep quality and associated sleep disorders are associated with increased risk of job injury and multiple mental and physical health problems, scant research has examined sleep quality among Latino farmworkers. Interviews were conducted with 371 male Latino farmworkers working in North Carolina during the 2010 agricultural season. Data on housing quality and sleep quality were collected. Access to air conditioning was significantly and positively associated with good sleep quality. This association remained when other housing characteristics and individual health indicators were controlled. Good sleep quality was associated with low levels of pain, depression, and anxiety. Poor sleep quality among Latino farmworkers was associated with poorer indicators of health. One important indicator of housing quality, air conditioning, was associated with better sleep quality. Further research is required to delineate how to improve the adequacy of farmworker housing to improve sleep quality and other health indicators.

Age at asthma onset and subsequent asthma outcomes among adults with active asthma.

INTRODUCTION: Little is known about the extent to which the age at which asthma first began influences respiratory health later in life. We conducted these analyses to examine the relationship between age at asthma onset and subsequent asthma-related outcomes. METHODS: We used data from 12,216 adults with asthma who participated in the 2010 Behavioral Risk Factor Surveillance System Asthma Call-back Survey to describe the distribution of age at asthma onset. Linear regression was used to estimate associations of age at asthma onset with asthma-related outcomes, including symptoms in the past 30 days and asthma-related emergency visits. RESULTS: Asthma onset before age 16 was reported by an estimated 42% of adults with active asthma, including 14% with onset at 5-9 years of age who reported experiencing any asthma symptoms on 21% of days in the past month. Compared to this group, the percentage of days in the past month with any asthma symptoms was 14.8% higher (95% confidence interval (CI): 5.4, 24.1) among those whose asthma onset occurred at <1 year. When age at onset occurred at 10 years or older there was little change in the prevalence of asthma-related emergency visits across age at onset categories. CONCLUSION: Age at asthma onset may affect subsequent asthma-related outcomes.

Conventional and endobronchial ultrasound-guided transbronchial needle aspiration: complementary procedures.

OBJECTIVE: The diagnosis of mediastinal and hilar lymphadenopathy and staging lung cancer with endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) are on the rise. Most reports have demonstrated high yields with EBUS-TBNA and superiority of this procedure over conventional TBNA (cTBNA), but the relative roles of these procedures remain undefined. We present a comprehensive comparison of EBUS-TBNA to cTBNA. METHODS: We reviewed all of the bronchoscopies performed at our medical center from January 2009 through December 2010. We collected data on 82 EBUS-TBNAs and 209 cTBNAs performed. A cost analysis was subsequently performed. RESULTS: EBUS-TBNA was performed more often in patients with known prior cancer and suspicion of recurrence or staging compared with cTBNA (42% vs 18%, P < 0.001). cTBNA was more likely to be performed in patients suspected of having malignancy and needing diagnostic specimens (70% vs 46%, P = 0.009). The overall yield in which a diagnostic specimen or lymphoid tissue was obtained was not different in each group: EBUS 84% vs cTBNA 86% (P = 0.75). The cancer yield was 57% in cTBNAs compared with 44% in EBUS-TBNAs (P < 0.0001), with EBUS-TBNA more often targeting smaller nodes (mean 15 ± 7 mm vs 21 ± 11 mm; P < 0.0001) and paratracheal sites (67% vs 49%, P = 0.003). Per-procedure cost using a Medicare scale was higher for EBUS than it was for cTBNA ($1195 vs $808; P < 0.001). CONCLUSIONS: EBUS-TBNA and cTBNA are complementary bronchoscopic procedures, and the appropriate diagnostic modality can be selected in a cost-effective manner based upon the primary indication for TBNA, lymph node size, and lymph node location.

Poultry processing work and respiratory health of Latino men and women in North Carolina.

OBJECTIVE: To evaluate associations between poultry processing work and respiratory health among working Latino men and women in North Carolina. METHODS: Between May 2009 and November 2010, 402 poultry processing workers and 339 workers in a comparison population completed interviewer-administered questionnaires. Of these participants, 279 poultry processing workers and 222 workers in the comparison population also completed spirometry testing to provide measurements of forced expiratory volume in 1 second and forced vital capacity. RESULTS: Nine percent of poultry processing workers and 10% of workers in the comparison population reported current asthma. Relative to the comparison population, adjusted mean forced expiratory volume in 1 second and forced vital capacity were lower in the poultry processing population, particularly among men who reported sanitation job activities. CONCLUSIONS: Despite the low prevalence of respiratory symptoms reported, poultry processing work may affect lung function.