Anita A. Shah

Comparison of Adjustable and Fixed Oral Appliances for the Treatment of Obstructive Sleep Apnea

STUDY OBJECTIVES To compare the efficacy of adjustable and fixed oral appliances for the treatment of OSA. METHODS Retrospective review of consecutive patients with OSA treated with either adjustable or fixed oral appliances. Polysomnography was conducted before and during therapy. Effective treatment was defined as an apnea-hypopnea index (AHI) < 5 events/h or < 10 events/h with resolution of sleepiness (Epworth < 10). We compared efficacy rates between fixed and adjustable appliances and sought to identify factors associated with greater success. RESULTS We included 805 patients, 602 (74.8%) treated with an adjustable and 203 (25.2%) a fixed oral appliances. Among the cohort, 86.4% were men; mean age was 41.3 ± 9.2 years. Mean AHI was 30.7 ± 25.6, with 34.1% having mild (AHI 5-14.9), 29.2% moderate (AHI 15-29.9), and 36.8% severe (AHI ≥ 30) OSA. Successful therapy was significantly more common with adjustable appliances. Obstructive events were reduced to < 5/h in 56.8% with adjustable compared to 47.0% with fixed appliances (p = 0.02). Similarly, a reduction of events to < 10 with resolution of sleepiness occurred in 66.4% with adjustable appliances versus 44.9% with fixed appliances (p < 0.001). For both devices, success was more common in younger patients, with lower BMI and less severe disease. CONCLUSIONS Adjustable devices produced greater reductions in obstructive events and were more likely to provide successful therapy, especially in moderate-severe OSA. Fixed appliances were effective in mild disease, but were less successful in those with higher AHIs. Given these findings, the baseline AHI should be considered when selecting the type of oral appliance.

An intensivist-directed intensive care unit improves clinical outcomes in a combat zone

Objective: Intensivist-directed intensive care units (ICUs) have been shown to improve clinical outcomes. Numerous barriers exist that limit hospitals adopting this practice. We sought to show this staffing model can be implemented in an austere environment with limited resources resulting in improved outcomes. Design: We conducted a retrospective observational cohort study of consecutive adult patients admitted to the ICU between March 2004 and January 2007. Setting: This study was conducted in an ICU in a U.S. Army Combat Support Hospital deployed to Afghanistan. Patients: North Atlantic Trade Organization members (U.S. military service members, American civilian contractors, members of the North Atlantic Trade Organization Coalition International Security Assistance Force), members of the Afghanistan National Army and National Police, and local Afghani nationals were included in the study. Both traumatic injuries and medical illnesses were treated. Interventions: During the observation period, the ICU was converted from an open model to an intensivist-directed model. Measurements and Main Results: Outcomes compared between the two models included ICU and hospital mortality, duration of mechanical ventilation, and ventilator-associated pneumonia rates. During the observation period, there were 2740 admissions, 965 of which were initially admitted to the ICU. We found significant reductions in ICU mortality (6.6% vs. 4.0%, p < 0.001), duration of mechanical ventilation (4.7 ± 3.9 days vs. 3.1 ± 2.7 days, p < 0.001), and rates of ventilator-associated pneumonia (42.5% vs. 8.0%; p < 0.001). Conclusions: Transition to an intensivist-directed ICU in an Army Combat Support Hospital improved outcomes among ICU patients. This study demonstrates the feasibility of using this model in an austere, combat environment.