Sleep-Related Hallucinations.

The diagnostic category of sleep-related hallucinations (SRH) replaces the previous category of Terrifying Hypnagogic Hallucinations in the 2001 edition of International Classification of Sleep Disorders-R. Hypnagogic and hypnopompic hallucinations (HHH) that occur in the absence of other symptoms or disorder and, within the limits of normal sleep, are most likely non-pathological. By contrast, complex nocturnal visual hallucinations (CNVH) may reflect a dimension of psychopathology reflecting different combinations of etiologic influences. The identification and conceptualization of CNVH is relatively new, and more research is needed to clarify whether CNVH share common mechanisms with HHH.

Telemedicine compared to standard face-to-face care for continuous positive airway pressure treatment: real-world Australian experience.

STUDY OBJECTIVES: We tested a telemedicine model of care to initiate continuous positive airway pressure (CPAP) for patients with obstructive sleep apnea (OSA) living in remote Western Australia. METHODS: A prospective study comparing telemedicine for CPAP initiation in a remote population versus standard face-to-face CPAP initiation in a metropolitan population. The primary outcome was average nightly CPAP use in the final week of a CPAP trial. RESULTS: A total of 186 participants were allocated to either telemedicine (n = 56) or standard care (n = 130). The average distance from the study center for the telemedicine group was 979 km (±792 km) compared to 19 km (±14 km) for the standard care group. The CPAP trial duration in the standard care group was less than the telemedicine group (37.6 vs 69.9 days, p < .001). CPAP adherence in the telemedicine group was not inferior to standard care (Standard 4.7 ± 0.2 h, Telemedicine 4.7 ± 0.3 h, p = 0.86). No differences were found between groups in residual apnea-hypopnea index, symptom response, sleep specific quality of life at the end of the trial, and continued CPAP use (3-6 months). Participant satisfaction was high in both groups. Total health care costs of the telemedicine model were less than the standard model of care. An estimated A$4538 per participant in travel costs was saved within the telemedicine group by reducing the need to travel to the sleep center for in-person management. CONCLUSIONS: In remote dwelling adults starting CPAP for the treatment of OSA, outcomes using telemedicine were comparable to in-person management in a metropolitan setting.

The changing profile of obstructive sleep apnea: long term trends in characteristics of patients presenting for diagnostic polysomnography.

Introduction: We aimed to analyze long-term trends in characteristics of patients undergoing diagnostic polysomnography (PSG) and subsequently diagnosed with obstructive sleep apnea (OSA) to inform delivery of sleep services. Material and Methods: We studied 24,510 consecutive patients undergoing PSG at a tertiary-care sleep service between 1989 and 2013. OSA was defined by an apnea hypopnea index (AHI)≥ 5 events/hour. Changes to hypopnea definition and flow sensing techniques in 2002 created two distinct AHI scoring periods: American Sleep Disorders Association (ASDA) 1989 - July 2002 and American Academy of Sleep Medicine (Chicago) from August 2002. Results: Over 23.5 years there was a steady increase in proportion of females (15% to 45%), small increases in average age and BMI, and a small decline in socioeconomic status in the overall group. AHI varied between scoring periods both overall [ASDA 10.8/h (3.2-29.6), Chicago 24.3/h (11.8-48.1)] and in the large subgroup (80.7%) diagnosed with OSA [ASDA 20.7/h (10.6-44.1), Chicago 27.4/h (14.8-51.5)]. OSA diagnosis rates increased in the Chicago period (ASDA 66%, Chicago 91%). Increases in AHI and proportion diagnosed appeared better explained by changes in scoring methods than key OSA risk factors. Conclusion: Temporal increases in proportion of females and decreases in socioeconomic status of people undergoing PSG may reflect greater community awareness of sleep disorders. Temporal increases in age and obesity are consistent with secular trends. Changes in scoring methods have major impacts on OSA diagnosis and judgement of disease severity, with important implications for contemporary resourcing of sleep services and interpretation of historical OSA data.

Obstructive Sleep Apnea Is Treatable With Continuous Positive Airway Pressure in People With Schizophrenia and Other Psychotic Disorders.

Obstructive sleep apnea (OSA) is a highly prevalent condition in people living with schizophrenia or other psychotic disorder. Its treatment with continuous positive airway pressure therapy (CPAP) can dramatically improve daytime and physical health function. People with a psychotic disorder, however, are rarely diagnosed and treated and there are no large-scale studies showing evidence of successful treatment with CPAP. Using a retrospective case-control study approach (N = 554), we examined adherence to and effectiveness of a CPAP trial in individuals with comorbid psychotic disorder and OSA (psychosis group, n = 165) referred for a CPAP trial at the West Australian Sleep Disorders Research Institute. Given that antipsychotic medication is an important confounder, we included a psychiatric (non-psychosis) comparison group taking antipsychotic medication (antipsychotic group, n = 82), as well as a nonpsychiatric control group (OSA control group, n = 307) also diagnosed with OSA and referred for CPAP. Variables included OSA symptom response, CPAP engagement, and usage at 3 months. The Psychosis group had the most severe OSA at baseline and they attended fewer clinic appointments overall. However, there were no other group differences either in CPAP adherence or treatment response. CPAP was equally effective in normalizing OSA symptoms and daytime sleepiness in all groups. CPAP usage was longer per night in the Psychosis and Antipsychotic groups, perhaps suggesting a role of sedation from antipsychotic medications. In conclusion, OSA is treatable and CPAP feasible in people with severe mental illness and antipsychotic medications are not a barrier to treatment response.

Continuous positive airway pressure and adverse cardiovascular events in obstructive sleep apnea: are participants of randomized trials representative of sleep clinic patients?

STUDY OBJECTIVES: Randomized controlled trials (RCTs) have shown no reduction in adverse cardiovascular (CV) events in patients randomized to continuous positive airway pressure (CPAP) therapy for obstructive sleep apnea (OSA). This study examined whether randomized study populations were representative of OSA patients attending a sleep clinic. METHODS: Sleep clinic patients were 3,965 consecutive adults diagnosed with OSA by in-laboratory polysomnography from 2006 to 2010 at a tertiary hospital sleep clinic. Characteristics of these patients were compared with participants of five recent RCTs examining the effect of CPAP on adverse CV events in OSA. The percentage of patients with severe (apnea-hypopnea index, [AHI] ≥ 30 events/h) or any OSA (AHI ≥ 5 events/h) who met the eligibility criteria of each RCT was determined, and those criteria that excluded the most patients identified. RESULTS: Compared to RCT participants, sleep clinic OSA patients were younger, sleepier, more likely to be female and less likely to have established CV disease. The percentage of patients with severe or any OSA who met the RCT eligibility criteria ranged from 1.2% to 20.9% and 0.8% to 21.9%, respectively. The eligibility criteria that excluded most patients were preexisting CV disease, symptoms of excessive sleepiness, nocturnal hypoxemia and co-morbidities. CONCLUSIONS: A minority of sleep clinic patients diagnosed with OSA meet the eligibility criteria of RCTs of CPAP on adverse CV events in OSA. OSA populations in these RCTs differ considerably from typical sleep clinic OSA patients. This suggests that the findings of such OSA treatment-related RCTs are not generalizable to sleep clinic OSA patients.Randomized Intervention with Continuous Positive Airway Pressure in CAD and OSA (RICCADSA) trial, https://clinicaltrials.gov/ct2/show/NCT00519597, ClinicalTrials.gov number, NCT00519597.Usefulness of Nasal Continuous Positive Airway Pressure (CPAP) Treatment in Patients with a First Ever Stroke and Sleep Apnea Syndrome, https://clinicaltrials.gov/ct2/show/NCT00202501, ClinicalTrials.gov number, NCT00202501.Effect of Continuous Positive Airway Pressure (CPAP) on Hypertension and Cardiovascular Morbidity-Mortality in Patients with Sleep Apnea and no Daytime Sleepiness, https://clinicaltrials.gov/ct2/show/NCT00127348, ClinicalTrials.gov number, NCT00127348.Continuous Positive Airway Pressure (CPAP) in Patients with Acute Coronary Syndrome and Obstructive Sleep Apnea (OSA) (ISAACC), https://clinicaltrials.gov/ct2/show/NCT01335087, ClinicalTrials.gov number, NCT01335087.

Vital capacity and oxygen saturation at rest and after exercise predict hypoxaemia during hypoxic inhalation test in patients with respiratory disease.

BACKGROUND AND OBJECTIVE: The hypoxic inhalation test (HIT) accurately predicts air travel hypoxaemia, but availability is limited. We assessed whether oxygen saturation (SpO2) during HIT can be predicted by simple measures of lung function and exercise-induced hypoxaemia. METHODS: Analysis of all patients who had HIT and lung function testing performed between January 2005 and April 2010. Prior to HIT, SpO(2) on room air was measured at rest and after 2 min of moderate exercise. HIT was conducted using fractional inspired oxygen concentration 0.14 and SpO(2) was measured after equilibration of ≥ 5 min. The relationships between SpO(2) during HIT (HIT SpO(2)) and resting SpO(2), post-exercise SpO(2), gas exchange (diffusing capacity for carbon monoxide) and ventilatory capacity were examined. Linear regression was performed to identify significant predictors of HIT SpO(2). RESULTS: 137 patients were studied: 70 had chronic obstructive pulmonary disease, 43 interstitial lung disease and 20 extra-pulmonary restriction. All patients with HIT SpO(2) ≤ 85% had post-exercise SpO(2) < 95% (n = 24 (18%)). HIT SpO(2) correlated best with post-exercise SpO(2) overall (r = 0.69, P < 0.01). Linear regression identified forced vital capacity % predicted, resting SpO(2) and post-exercise SpO(2) as independent predictors of HIT SpO(2). CONCLUSIONS: In patients with respiratory disease, post-exercise SpO(2) ≥ 95% on room air may be used to exclude the need for HIT to assess oxygen requirement for air travel. HIT SpO(2) can be estimated from forced vital capacity % predicted, resting SpO(2) and post-exercise SpO(2) using a linear regression model.

Interrelationships between body mass, oxygen desaturation, and apnea-hypopnea indices in a sleep clinic population.

STUDY OBJECTIVES: To investigate the relationship between oxygen desaturation index (ODI), body mass index (BMI), and apnea-hypopnea index (AHI) in a large sleep clinic population. DESIGN: Retrospective observational. SETTING: Sleep disorders clinic. PATIENTS OR PARTICIPANTS: 11,448 individuals undergoing diagnostic polysomnography (PSG) at a sleep disorders clinic. MEASUREMENTS AND RESULTS: Polysomnography were scored using Chicago criteria. ODI at 2%, 3%, and 4% threshold levels were derived. The study population was subdivided into BMI categories in steps of 5 kg/m(2). Mean ODI and the accuracy of ODI for detecting an AHI ≥ 15 (moderate-severe OSA) or ≥ 30 (severe OSA) were examined by BMI category, using the area under the curve (AUC) of receiver operator characteristic (ROC) curves for the 3 ODI thresholds. Based on AUC, ODI-3% performed best overall, achieving a significantly higher AUC than ODI-2% and ODI-4% for the diagnosis of moderate-severe OSA, and a higher AUC than ODI-2% for the diagnosis of severe OSA. When examining the effect of BMI, ODI-3% achieved a significantly higher AUC than ODI-2% in all BMI categories, and ODI-4% in non-obese subjects. The sensitivity of ODI for detecting OSA increased with BMI, while specificity decreased. CONCLUSIONS: ODI-3% performed best overall, and when combined with appropriate clinical assessment, could be considered as an initial diagnostic test for OSA. OSA is more frequently associated with oxygen desaturation in obese subjects. BMI influences the accuracy of ODI for the diagnosis of OSA, and ODI should not be used in isolation as a test for OSA in subjects with a BMI below 25kg/m(2).

Posture influences patient cough rate, sedative requirement and comfort during bronchoscopy: An observational cohort study.

OBJECTIVES: To investigate differences between semi-recumbent and supine postures in terms of cough rate, oxygen desaturation, sedative use, and patient comfort during the initial phase of bronchoscopy. METHODS: Consecutive bronchoscopy patients (n = 69) participated in this observational cohort study. Posture was determined by the bronchoscopist's usual practice. Patient demographics, spirometry, pulse, and SpO2 were recorded. The initial phase was defined as the time from bronchoscopy insertion to visualisation of both distal main bronchi. Cough rate, peak pulse, nadir SpO2, oxygen supplementation, and sedative use during the initial phase were recorded. A post-procedure questionnaire was administered to the patient and the attending nurse. RESULTS: 36 patients had bronchoscopy in the semi-recumbent posture, 33 in the supine posture. 3 of 5 bronchoscopists performed in both postures. There were no differences in baseline parameters between the groups. The semi-recumbent posture resulted in significantly less cough (mean (SD) 3.6 (2.3) vs. 6.1 (4.5) coughs/min, p = 0.007) and less fentanyl use (70 (29) vs. 88 (28) mcg, p = 0.011) in the initial phase. There were no significant differences in the nadir SpO2, fall in SpO2, oxygen supplementation, or increase in pulse rate between the groups. On 100 mm visual analogue scale, nurse perception of patient discomfort was lower in the semi-recumbent position (23 (21) vs. 39 (28) mm, p = 0.01), and there was a trend towards less patient perceived cough in the semi-recumbent group (28 (25) vs. 40 (28) mm, p = 0.06). CONCLUSIONS: Bronchoscopy performed in the semi-recumbent posture results in less cough and sedative requirement, and may improve patient comfort.

Multiple endobronchial polyps.

Multiple endobronchial polyps are a rare finding. We describe a case of multiple benign endobronchial polyps in a 60-year-old woman who presented with a chronic cough and occasional hemoptysis. Chest computed tomography revealed bilateral basal cylindrical bronchiectasis, with filling defects in both main bronchi. Bronchoscopy revealed the presence of polyps in the distal trachea, both main bronchi, and in the lobar and segmental bronchi of all lobes of both lungs, with lesions from 2 to 10 mm in diameter. Larger lesions were treated with argon plasma coagulation. Histopathology was consistent with benign fibroepithelial polyps. Culture from bronchial washings isolated Pseudomonas aeruginosa, and the patient was treated with ciprofloxacin followed by a prolonged course of azithromycin. Symptoms improved, and repeat bronchoscopy at 3 and 6 months revealed complete resolution of all polyps.

Pandemic influenza (H1N1) 2009 pneumonia: CURB-65 score for predicting severity and nasopharyngeal sampling for diagnosis are unreliable.

BACKGROUND: From the first case reports of pandemic influenza (H1N1) 2009 it was clear that a significant proportion of infected individuals suffered a primary viral pneumonia. The objective of this study was twofold; to assess the utility of the CURB-65 community acquired pneumonia (CAP) severity index in predicting pneumonia severity and ICU admission, and to assess the relative sensitivity of nasopharyngeal versus lower respiratory tract sampling for the detection of pandemic influenza (H1N1) CAP. METHODS: A retrospective cohort study of 70 patients hospitalised for pandemic influenza (H1N1) 2009 in an adult tertiary referral hospital. Characteristics evaluated included age, pregnancy status, sex, respiratory signs and symptoms, smoking and alcohol history, CURB-65 score, co-morbidities, disabling sequelae, length of stay and in-hospital mortality outcomes. Laboratory features evaluated included lymphocyte count, C-reactive protein (CRP), nasopharyngeal and lower respiratory tract pandemic influenza (H1N1) 2009 PCR results. RESULTS: Patients with pandemic (H1N1) 2009 influenza CAP differed significantly from those without pneumonia regarding length of stay, need for ICU admission, CRP and the likelihood of disabling sequelae. The CURB-65 score did not predict CAP severity or the need for ICU admission (only 2/11 patients admitted to ICU had CURB-65 scores of 2 or 3). Nasopharyngeal specimens for PCR were only 62.9% sensitive in CAP patients compared to 97.8% sensitivity for lower respiratory tract specimens. CONCLUSIONS: The CURB-65 score does not predict severe pandemic influenza (H1N1) 2009 CAP or need for ICU admission. Lower respiratory tract specimens should be collected when pandemic (H1N1) 2009 influenza CAP is suspected.