Does testing for sleep-disordered breathing predischarge vs postdischarge result in different treatment outcomes?

STUDY OBJECTIVES: Treatment of sleep-disordered breathing may improve health-related outcomes postdischarge. However timely definitive sleep testing and provision of ongoing therapy has been a challenge. Little is known about how the time of testing-during hospitalization vs after discharge-affects important outcomes such as treatment adherence. METHODS: We conducted a 10-year retrospective study of hospitalized adults who received an inpatient sleep medicine consultation for sleep-disordered breathing and subsequent sleep testing. We divided them into inpatient and outpatient sleep testing cohorts and studied their clinical characteristics, follow-up, positive airway pressure adherence, pressure adherence, hospital readmission and mortality. RESULTS: Of 485 patients, 226 (47%) underwent inpatient sleep testing and 259 (53%) had outpatient sleep testing. The median age was 68 years old (interquartile range = 57-78), and 29.6% were females. The inpatient cohort had a higher Charlson Comorbidity Index (4 [3-6] vs 3[2-5], P ≤ .0004). A higher Charlson Comorbidity Index (hazard ratio = 1.14, 95% confidence interval:1.03-1.25, P = .001), body mass index (hazard ratio = 1.03, 95% confidence interval:1.0-1.05, P = .008), and stroke (hazard ratio = 2.22, 95% confidence interval:1.0-4.9, P = .049) were associated with inpatient sleep testing. The inpatient cohort kept fewer follow-up appointments (39.90% vs 50.62%, P = .03); however positive airway pressure adherence was high among those keeping follow-up appointments (88.9% [inpatient] vs 85.71% [outpatient], P = .55). The inpatient group had an increased risk for death (hazard ratio: 1.82 95% confidence interval 1.28-2.59, P ≤ .001) but readmission rates did not differ. CONCLUSIONS: Medically complex patients were more likely to receive inpatient sleep testing but less likely to keep follow-up, which could impact adherence and effectiveness of therapy. Novel therapeutic interventions are needed to increase sleep medicine follow-up postdischarge, which may result in improvement in health outcomes in hospitalized patients with sleep-disordered breathing. CITATION: Orbea CP, Jenad H, Kassab LL, et al. Does testing for sleep-disordered breathing predischarge vs postdischarge result in different treatment outcomes? J Clin Sleep Med. 2021;17(12):2451-2460.

Antifibrotics Modify B-Cell-induced Fibroblast Migration and Activation in Patients with Idiopathic Pulmonary Fibrosis.

B-cell activation is increasingly linked to numerous fibrotic lung diseases, and it is well known that aggregates of lymphocytes form in the lung of many of these patients. Activation of B-cells by pattern recognition receptors (PRRs) drives the release of inflammatory cytokines, chemokines, and metalloproteases important in the pathophysiology of pulmonary fibrosis. However, the specific mechanisms of B-cell activation in patients with idiopathic pulmonary fibrosis (IPF) are poorly understood. Herein, we have demonstrated that B-cell activation by microbial antigens contributes to the inflammatory and profibrotic milieu seen in patients with IPF. B-cell stimulation by CpG and ß-glucan via PRRs resulted in activation of mTOR-dependent and independent pathways. Moreover, we showed that the B-cell-secreted inflammatory milieu is specific to the inducing antigen and causes differential fibroblast migration and activation. B-cell responses to infectious agents and subsequent B-cell-mediated fibroblast activation are modifiable by antifibrotics, but each seems to exert a specific and different effect. These results suggest that, upon PRR activation by microbial antigens, B-cells can contribute to the inflammatory and fibrotic changes seen in patients with IPF, and antifibrotics are able to at least partially reverse these responses.

Noninvasive volume-assured pressure support for chronic respiratory failure: a review.

PURPOSE OF REVIEW: Noninvasive ventilation (NIV) is an established treatment for chronic hypercapnic respiratory failure (CRF). Volume-assured pressure support (VAPS) is a mode of NIV that automatically adjusts inspiratory pressure in order to maintain a constant respiratory volume. We aim to discuss the role and application of VAPS in CRF. RECENT FINDINGS: Recently published meta-analyses and reviews fail to demonstrate a significant difference in gas exchange, sleep, or quality-of-life improvement between VAPS and bilevel positive airway pressure (BPAP) in patients with CRF. A recent manuscript suggests that VAPS therapy in chronic obstructive pulmonary disease patients may reduce the number of exacerbations. It has been shown that with a protocol-driven approach BPAP and VAPS can both be successfully titrated during a single split-night polysomnography. SUMMARY: VAPS is as effective as other modes of NIV at improving ventilation and sleep in CRF. The potential advantage is a more consistent ventilatory support through daytime-nighttime variations and progression of disease over time. However, the impact on long-term outcomes, such as survival, has not been studied.

The Effect of Patient-Facing Applications on Positive Airway Pressure Therapy Adherence: A Systematic Review.

STUDY OBJECTIVES: Many patients struggle with adherence to positive airway pressure (PAP) therapy for sleep apnea. In this systematic review we examined the effect that patient-facing applications (PFA)-web-based applications that interact directly with the patient-have on PAP adherence. METHODS: A comprehensive search of PubMed, CINAHL, MEDLINE, and SCOPUS databases was performed. We looked for studies where: (1) patients were adults with sleep apnea initiating PAP therapy for the first time; (2) the intervention was a PFA that incorporated individual PAP use data; (3) the comparison was usual and/or telemedicine care, and (4) outcomes of objective PAP adherence data were recorded. RESULTS: Seven studies were identified (two randomized trials, one prospective cohort trial, four retrospective cohort studies). Cumulatively the studies enrolled 304,328 patients, with individual enrollment ranging between 61 and 172,678 patients. Six studies showed that PFA use was associated with using PAP for significantly more hours per night (range 0.7-1.3 hours more). PFA cohorts used PAP a greater proportion of nights and had a lower rate of mask leak. There was no difference in apnea-hypopnea index and self-reported measures of symptoms between study groups. CONCLUSIONS: PFA use was associated with improved adherence to PAP therapy. Although this conclusion is based on only two small trials and predominantly observational studies and therefore should be tested in large prospective trials, the PAFs are inexpensive, do not draw on health care resources, and show promise in improving PAP therapy for OSA.

Implementation of a New Guideline and Educational Sessions to Reduce Low-Value Continuous Pulse Oximetry Among Hospitalized Patients.

OBJECTIVES: The use of continuous pulse oximetry (CPOX) is ubiquitous among hospitalized patients, despite limited evidence that it improves clinical outcomes. The objective of this study was to reduce the use of CPOX among hospitalized patients in the nonintensive care unit and nonprogressive care unit settings. METHODS: This interventional trial included the creation a new local guideline for CPOX use and subsequent staff education. CPOX use, patient acuity, hospital length of stay, and code blue events were measured before and after the intervention. RESULTS: Postintervention there was a clinically significant and sustained decrease in CPOX use of 18% over 1 year. There were no significant changes postintervention in hospital length of stay or number of code blue events. CONCLUSIONS: Development of a guideline for CPOX use and staff education successfully led to a decrease in CPOX use, without an increase in hospital length of stay or code blue events.