Biren B. Kamdar

Sleep Deprivation in Critical Illness: Its Role in Physical and Psychological Recovery

Critically ill patients frequently experience poor sleep, characterized by frequent disruptions, loss of circadian rhythms, and a paucity of time spent in restorative sleep stages. Factors that are associated with sleep disruption in the intensive care unit (ICU) include patient-ventilator dysynchrony, medications, patient care interactions, and environmental noise and light. As the field of critical care increasingly focuses on patients’ physical and psychological outcomes following critical illness, understanding the potential contribution of ICU-related sleep disruption on patient recovery is an important area of investigation. This review article summarizes the literature regarding sleep architecture and measurement in the critically ill, causes of ICU sleep fragmentation, and potential implications of ICU-related sleep disruption on patients’ recovery from critical illness. With this background information, strategies to optimize sleep in the ICU are also discussed.

The effect of a quality improvement intervention on perceived sleep quality and cognition in a medical ICU.

Objectives:To determine if a quality improvement intervention improves sleep and delirium/cognition. Design:Observational, pre–post design. Setting:A tertiary academic hospital in the United States. Patients:300 medical ICU patients. Interventions:This medical ICU-wide project involved a “usual care” baseline stage, followed by a quality improvement stage incorporating multifaceted sleep-promoting interventions implemented with the aid of daily reminder checklists for ICU staff. Measurements and Main Results:Primary ICU outcomes were perceived sleep quality and noise ratings (measured on a 0–100 scale using the valid and reliable Richards–Campbell Sleep Questionnaire) and delirium/coma-free days. Secondary outcomes included ICU and hospital length of stay and mortality. Post-ICU measures of cognition and perceived sleep quality were evaluated in an ICU patient subset. During the baseline and sleep quality improvement stages, there were 122 and 178 patients, respectively, with more than one night in the ICU, accounting for 634 and 826 patient-days. Within the groups, 78 (63.9%) and 83 (46.6%) patients received mechanical ventilation. Over the 826 patient-day quality improvement period, checklist item completion rates ranged from 86% to 94%. In multivariable regression analysis of the quality improvement vs. baseline stages, improvements in overall Richards-Campbell Sleep Questionnaire sleep quality ratings did not reach statistical significance, but there were significant improvements in daily noise ratings (mean ± SD: 65.9±26.6 vs. 60.5±26.3, p = 0.001), incidence of delirium/coma (odds ratio: 0.46; 95% confidence interval, 0.23–0.89; p = 0.02), and daily delirium/coma-free status (odds ratio: 1.64; 95% confidence interval, 1.04–2.58; p = 0.03). Improvements in secondary ICU outcomes and post-ICU outcomes did not reach statistical significance. Conclusions:An ICU-wide quality improvement intervention to improve sleep and delirium is feasible and associated with significant improvements in perceived nighttime noise, incidence of delirium/coma, and daily delirium/coma-free status. Improvement in perceived sleep quality did not reach statistical significance.

Comparison of 21-Gauge and 22-Gauge Aspiration Needle in Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration: Results of the American College of Chest Physicians Quality Improvement Registry, Education, and Evaluation Registry

BACKGROUND Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure originally performed using a 22-gauge (22G) needle. A recently introduced 21-gauge (21G) needle may improve the diagnostic yield and sample adequacy of EBUS-TBNA, but prior smaller studies have shown conflicting results. To our knowledge, this is the largest study undertaken to date to determine whether the 21G needle adds diagnostic benefit. METHODS We retrospectively evaluated the results of 1,299 patients from the American College of Chest Physicians Quality Improvement Registry, Education, and Evaluation (AQuIRE) Diagnostic Registry who underwent EBUS-TBNA between February 2009 and September 2010 at six centers throughout the United States. Data collection included patient demographics, sample adequacy, and diagnostic yield. Analysis consisted of univariate and multivariate hierarchical logistic regression comparing diagnostic yield and sample adequacy of EBUS-TBNA specimens by needle gauge. RESULTS A total of 1,235 patients met inclusion criteria. Sample adequacy was obtained in 94.9% of the 22G needle group and in 94.6% of the 21G needle group (P = .81). A diagnosis was made in 51.4% of the 22G and 51.3% of the 21G groups (P = .98). Multivariate hierarchical logistic regression showed no statistical difference in sample adequacy or diagnostic yield between the two groups. The presence of rapid onsite cytologic evaluation was associated with significantly fewer needle passes per procedure when using the 21G needle (P < .001). CONCLUSIONS There is no difference in specimen adequacy or diagnostic yield between the 21G and 22G needle groups. EBUS-TBNA in conjunction with rapid onsite cytologic evaluation and a 21G needle is associated with fewer needle passes compared with a 22G needle.

Delirium transitions in the medical ICU: exploring the role of sleep quality and other factors.

Objectives:Disrupted sleep is a common and potentially modifiable risk factor for delirium in the ICU. As part of a quality improvement project to promote sleep in the ICU, we examined the association of perceived sleep quality ratings and other patient and ICU risk factors with daily transition to delirium. Design:Secondary analysis of prospective observational study. Setting:Medical ICU over a 201-day period. Patients:Two hundred twenty-three patients with greater than or equal to one night in the medical ICU in between two consecutive days of delirium assessment. Interventions:None. Measurements and Main Results:Daily perceived sleep quality ratings were measured using the Richards-Campbell Sleep Questionnaire. Delirium was measured twice daily using the Confusion Assessment Method for the ICU. Other covariates evaluated included age, sex, race, ICU admission diagnosis, nighttime mechanical ventilation status, prior day’s delirium status, and daily sedation using benzodiazepines and opioids, via both bolus and continuous infusion. Perceived sleep quality was similar in patients who were ever versus never delirious in the ICU (median [interquartile range] ratings, 58 [35–76] vs 57 [33–78], respectively; p = 0.71), and perceived sleep quality was unrelated to delirium transition (adjusted odds ratio, 1.00; 95% CI, 0.99–1.00). In mechanically ventilated patients, receipt of a continuous benzodiazepine and/or opioid infusion was associated with delirium transition (adjusted odds ratio, 4.02; 95% CI, 2.19–7.38; p < 0.001), and patients reporting use of pharmacological sleep aids at home were less likely to transition to delirium (adjusted odds ratio, 0.40; 95% CI, 0.20–0.80; p = 0.01). Conclusions:We found no association between daily perceived sleep quality ratings and transition to delirium. Infusion of benzodiazepine and/or opioid medications was strongly associated with transition to delirium in the ICU in mechanically ventilated patients and is an important, modifiable risk factor for delirium in critically ill patients.

Titles versus titles and abstracts for initial screening of articles for systematic reviews

Background There is no consensus on whether screening titles alone or titles and abstracts together is the preferable strategy for inclusion of articles in a systematic review. Methods Two methods of screening articles for inclusion in a systematic review were compared: titles first versus titles and abstracts simultaneously. Each citation found in MEDLINE or Embase was reviewed by two physician reviewers for prespecified criteria: the citation included (1) primary data; (2) the exposure of interest; and (3) the outcome of interest. Results There were 2965 unique citations. The titles first strategy resulted in an immediate rejection of 2558 (86%) of the records after reading the title alone, requiring review of 239 titles and abstracts, and subsequently 176 full text articles. The simultaneous titles and abstracts review led to rejection of 2782 citations (94%) and review of 183 full text articles. Interreviewer agreement to include an article for full text review using the titles-first screening strategy was 89%–94% (kappa = 0.54) and 96%–97% (kappa = 0.56) for titles and abstracts combined. The final systematic review included 13 articles, all of which were identified by both screening strategies (yield 100%, burden 114%). Precision was higher in the titles and abstracts method (7.1% versus 3.2%) but recall was the same (100% versus 100%), leading to a higher F-measure for the titles and abstracts approach (0.1327 versus 0.0619). Conclusion Screening via a titles-first approach may be more efficient than screening titles and abstracts together.

Original ResearchPulmonary ProceduresComparison of 21-Gauge and 22-Gauge Aspiration Needle in Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration: Results of the American College of Chest Physicians Quality Improvement Registry, Education, and Evaluation Registry

BACKGROUND Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure originally performed using a 22-gauge (22G) needle. A recently introduced 21-gauge (21G) needle may improve the diagnostic yield and sample adequacy of EBUS-TBNA, but prior smaller studies have shown conflicting results. To our knowledge, this is the largest study undertaken to date to determine whether the 21G needle adds diagnostic benefit. METHODS We retrospectively evaluated the results of 1,299 patients from the American College of Chest Physicians Quality Improvement Registry, Education, and Evaluation (AQuIRE) Diagnostic Registry who underwent EBUS-TBNA between February 2009 and September 2010 at six centers throughout the United States. Data collection included patient demographics, sample adequacy, and diagnostic yield. Analysis consisted of univariate and multivariate hierarchical logistic regression comparing diagnostic yield and sample adequacy of EBUS-TBNA specimens by needle gauge. RESULTS A total of 1,235 patients met inclusion criteria. Sample adequacy was obtained in 94.9% of the 22G needle group and in 94.6% of the 21G needle group (P = .81). A diagnosis was made in 51.4% of the 22G and 51.3% of the 21G groups (P = .98). Multivariate hierarchical logistic regression showed no statistical difference in sample adequacy or diagnostic yield between the two groups. The presence of rapid onsite cytologic evaluation was associated with significantly fewer needle passes per procedure when using the 21G needle (P < .001). CONCLUSIONS There is no difference in specimen adequacy or diagnostic yield between the 21G and 22G needle groups. EBUS-TBNA in conjunction with rapid onsite cytologic evaluation and a 21G needle is associated with fewer needle passes compared with a 22G needle.

Sleep and Sleep Disordered Breathing in Hospitalized Patients

Sleep is a fundamental physiological process necessary for recovery from acute illness. Unfortunately for hospitalized patients, sleep is often short, fragmented, and poor in quality, and may be associated with adverse outcomes including inpatient delirium. Many factors contribute to poor sleep in the hospital setting, including preexisting sleep deprivation, sleep disordered breathing, environmental noise and light, patient care activities, and medications. Sleep disordered breathing increases the risk of potentially life-threatening cardiovascular, respiratory, and metabolic consequences, and therefore should be diagnosed and treated in hospitalized patients. Mitigating the sequelae associated with poor sleep quality and sleep disordered breathing requires early identification of modifiable factors impacting a patients sleep, including engagement of a multidisciplinary team. In this article, we review the current knowledge of sleep in hospitalized patients with a detailed focus on patients with sleep disordered breathing.

Developing, Implementing, and Evaluating a Multifaceted Quality Improvement Intervention to Promote Sleep in an ICU

Critically ill patients commonly experience poor sleep quality in the intensive care unit (ICU) because of various modifiable factors. To address this issue, an ICU-wide, multifaceted quality improvement (QI) project was undertaken to promote sleep in the Johns Hopkins Hospital Medical ICU (MICU). To supplement previously published results of this QI intervention, the present article describes the specific QI framework used to develop and implement this intervention, which consists of 4 steps: (a) summarizing the evidence to create a list of sleep-promoting interventions, (b) identifying and addressing local barriers to implementation, (c) selecting performance measures to assess intervention adherence and patient outcomes, and (d) ensuring that all patients receive the interventions through staff engagement and education and regular project evaluation. Measures of performance included daily completion rates of daytime and nighttime sleep improvement checklists and completion rates of individual interventions. Although long-term adherence and sustainability pose ongoing challenges, this model provides a foundation for future ICU sleep promotion initiatives.

Joblessness and Lost Earnings after Acute Respiratory Distress Syndrome in a 1-Year National Multicenter Study

Rationale: Following acute respiratory distress syndrome (ARDS), joblessness is common but poorly understood. Objectives: To evaluate the timing of return to work after ARDS, and associated risk factors, lost earnings, and changes in healthcare coverage Methods: Over 12‐month longitudinal follow‐up, ARDS survivors from 43 U.S. ARDSNet hospitals provided employment and healthcare coverage data via structured telephone interviews. Factors associated with the timing of return to work were assessed using Fine and Gray regression analysis. Lost earnings were estimated using Bureau of Labor Statistics data. Measurements and Main Results: Of 922 consenting survivors, 386 (42%) were employed before ARDS (56% male; mean ± SD age, 45 ± 13 yr), with seven dying by 12‐month follow‐up. Of 379 previously employed 12‐month survivors, 166 (44%) were jobless at 12‐month follow‐up. Accounting for competing risks of death and retirement, half of enrolled and previously employed survivors returned to work by 13 weeks after hospital discharge, with 68% ever returning by 12 months. Delays in return to work were associated with longer hospitalization and older age among nonwhite survivors. Over 12‐month follow‐up, 274 (71%) survivors accrued lost earnings, averaging

Self-Reported Sleep and Breathing Disturbances in Joubert Syndrome

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