David A. Schulman

Continuous positive airway pressure treatment of sleepy patients with milder obstructive sleep apnea: results of the CPAP Apnea Trial North American Program (CATNAP) randomized clinical trial.

RATIONALE Twenty-eight percent of people with mild to moderate obstructive sleep apnea experience daytime sleepiness, which interferes with daily functioning. It remains unclear whether treatment with continuous positive airway pressure improves daytime function in these patients. OBJECTIVES To evaluate the efficacy of continuous positive airway pressure treatment to improve functional status in sleepy patients with mild and moderate obstructive sleep apnea. METHODS Patients with self-reported daytime sleepiness (Epworth Sleepiness Scale score >10) and an apnea-hypopnea index with 3% desaturation and from 5 to 30 events per hour were randomized to 8 weeks of active or sham continuous positive airway pressure treatment. After the 8-week intervention, participants in the sham arm received 8 weeks of active continuous positive airway pressure treatment. MEASUREMENTS AND MAIN RESULTS The Total score on the Functional Outcomes of Sleep Questionnaire was the primary outcome measure. The adjusted mean change in the Total score after the first 8-week intervention was 0.89 for the active group (n = 113) and -0.06 for the placebo group (n = 110) (P = 0.006). The group difference in mean change corresponded to an effect size of 0.41 (95% confidence interval, 0.14-0.67). The mean (SD) improvement in Functional Outcomes of Sleep Questionnaire Total score from the beginning to the end of the crossover phase (n = 91) was 1.73 ± 2.50 (t[90] = 6.59; P < 0.00001) with an effect size of 0.69. CONCLUSIONS Continuous positive airway pressure treatment improves the functional outcome of sleepy patients with mild and moderate obstructive sleep apnea.

The Appearance of Central Sleep Apnea After Treatment of Obstructive Sleep Apnea

Patients with a primary diagnosis of obstructive sleep apnea frequently demonstrate central sleep apnea that emerges during treatment with CPAP. Although a number of mechanisms for this finding have been hypothesized, the pathophysiology is not definitively known. Controversy exists as to whether the concomitant appearance of the two phenomena represents a distinct meaningful entity. Regardless, the coincidence of these diseases may have important clinical implications. Herein, we review the proposed mechanisms for obstructive sleep apnea complicated by central sleep apnea. Future research is needed to elucidate the relative importance and susceptibility to intervention of the various pathophysiologic mechanisms responsible for this phenomenon, and whether a treatment approach distinct from that of pure obstructive apnea is justified.

Obstructive Sleep Apnea and Cardiovascular Disease

Opinion statementObstructive sleep apnea is a highly prevalent disease that often goes undetected for many years before diagnosis. Although most patients seek treatment to improve symptoms of daytime sleepiness, a growing body of literature suggests that treatment may also modulate cardiovascular risk. This article summarizes the current literature regarding the associations between sleep-disordered breathing and adverse cardiovascular outcomes and reviews the lesser body of data demonstrating the cardiovascular benefits of therapy.

Effect of supine knee position on obstructive sleep apnea

We previously reported a case of a middle-aged man whose obstructive sleep apnea (OSA) was virtually eliminated when he slept in the supine “knees up” position. In this study, we attempt to replicate this phenomenon in a group of volunteers with previously diagnosed OSA. Results indicated no significant improvement in OSA when sleeping supine knees up. Examination of distribution of within subjects’ change [calculated as Respiratory Disturbance Index (RDI) in the “knees down” position vs RDI in the knees up position] indicated a trend for improvement in the latter (p=0.12, two-tailed probability). These results suggest that knee position is unlikely to be a robust intervention for OSA though they allow for the possibility that some patients may have a moderation of their condition by such a manipulation.

Improvement in obstructive sleep apnea in the supine knees-up position.

We report a 38-year-old man with obstructive sleep apnea whose sleep-disordered breathing was substantially reduced by sleep in the supine, “knees-up” position, relative to his sleep in the customary supine, “knees-down” position. No obvious anatomic or pathophysiologic alterations explained this phenomenon. The effect was reproducible in the patient 4 years later. Potential mechanisms underlying such improvement, including alterations in upper airway/lung volume dependence and venous supply to upper airway vasculature, are discussed. This manipulation could be an important adjunctive treatment for a subset of obstructive sleep apnea patients demonstrating such an effect.

Evaluating Simulation-Based ACLS Education on Patient Outcomes: A Randomized, Controlled Pilot Study

BACKGROUND Simulation training is widely accepted as an effective teaching tool, especially for dealing with high-risk situations. OBJECTIVE We assessed whether standardized, simulation-based advanced cardiac life support (ACLS) training improved performance in managing simulated and actual cardiac arrests. METHODS A total of 103 second- and third-year internal medicine residents were randomized to 2 groups. The first group underwent conventional ACLS training. The second group underwent two 2 1/2-hour sessions of standardized simulation ACLS teaching. The groups were assessed by evaluators blinded to their assignment during in-hospital monthly mock codes and actual inpatient code sheets at 3 large academic hospitals. Primary outcomes were time to initiation of cardiopulmonary resuscitation, time to administration of first epinephrine/vasopressin, time to delivery of first defibrillation, and adherence to American Heart Association guidelines. RESULTS There were no differences in primary outcomes among the study arms and hospital sites. During 21 mock codes, the most common error was misidentification of the initial rhythm (67% [6 of 9] and 58% [7 of 12] control and simulation arms, respectively, P  =  .70). There were no differences in primary outcome among groups in 147 actual inpatient codes. CONCLUSIONS This blinded, randomized study found no effect on primary outcomes. A notable finding was the percentage of internal medicine residents who misidentified cardiac arrest rhythms.

Organization and Structure for Sleep Medicine Programs at Academic Institutions: Part 1—Current Challenges

EXECUTIVE SUMMARY As a field that has emerged in recent years, from multidis ciplinary roots within long-standing, traditional academic infrastructures, sleep medicine has assumed highly disparate organizational structures at each institution. Access to the creativity, talent, trainees, administration, and financial investment of one or more departments at each medical center has contributed substantially to advances in sleep and biological rhythms. At the same time, however, the variability of the support structure across institutions and the ability of specific departments to develop only the most relevant aspects of a highly multidisciplinary field has substantially limited the growth of sleep medi cine. Surveys in 2009 and 2012 by a Presidential Task Force of the Sleep Research Society suggested that strong, independent, self-sufficient, and cohesive administrative structures for sleep medicine were rare, if not absent. Little progress had been made toward organizational structures envisioned in the 2006 Institute of Medicine report, Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. This white paper, written by members of the Academic Affairs Committee and then endorsed by the Boards of Directors of both the American Academy of Sleep Medicine and the Sleep Research Society, summarizes challenges to sleep medicine that arise at academic institutions. Examples of specific challenges discussed include the absence or rarity of: sleep center responsibility for sleep faculty recruitment; recruitment packages targeted for sleep; salary equity for identical work within the same sleep center by members of different departments; better equity between academic and nonacademic salaries; reinvestment of clinical or other margins back into sleep; access by qualified individuals to academic positions regardless of original specialty training before sleep; oversight of research space and resources by sleep centers; department-blind access to trainees who stand to gain most from training in sleep

Inter-rater Agreement for Visual Discrimination of Phasic and Tonic Electromyographic Activity in Sleep.

Study Objectives The objective of this study was to determine the confidence of expert raters in discriminating phasic and tonic electromyographic (EMG) activity. We undertook this study because we suspected that even expert scorers may disagree on whether a given EMG segment contained phasic activity, tonic activity, or both. Methods Six individuals holding either Fellowship status in the American Academy of Sleep Medicine or Board Certification in Sleep Medicine with at least 5 years experience in interpreting polysomnography visually examined 60 segments containing EMG activity. Raters determined their relative confidence that each segment contained phasic and tonic activity by noting whether they were highly certain or somewhat certain that the segment contained such activity or somewhat certain or highly certain that each segment did not contain such activity. Every segment was rated by every rater twice, once for phasic and once for tonic activity. Results Substantial differences among raters existed in certainty regarding presence/absence of both phasic and tonic activity, although raters agreed on segments far above chance. Consensus was higher on certainty regarding presence of phasic, relative to tonic, activity. Conclusions These findings indicate the limitations of visual analyses for discriminating abnormal muscle activity during sleep. Conversely, when expert judgments are combined with digitized measurements of EMG activity in sleep (e.g. REM atonia index), some allowance must be made for the unique contribution of visual analyses to such judgments, most notably for short duration EMG signals. These results may have relevance for polysomnographic interpretation in suspected synucleinopathies.

CHEST: Home of the Clinician-Educator

Many hands can build a house; it takes trust to make that house a home. Trust has two main components: credibility (worthiness based on preparation and past performance) and empathy (the ability to understand and share another persons values). CHEST has maintained its credibility and empathy as the global leader in clinical pulmonary, critical care, and sleep medical education. It follows that the leader in chest clinical education would also be the home of the clinician-educator. You are that educator.

A Sleep Medicine Curriculum for Pulmonary and Pulmonary / Critical Care Fellowship Programs – A Multi-Society Expert Panel Report

BACKGROUND: Pulmonary medicine specialists find themselves responsible for the diagnosis and management of patients with sleep disorders. Despite the increasing prevalence of many of these conditions, many sleep medicine fellowship training slots go unfilled, leading to a growing gap between the volume of patients seeking care for sleep abnormalities and the number of physicians formally trained to manage them. To address this need, we convened a multisociety panel to develop a list of curricular recommendations related to sleep medicine for pulmonary fellowship training programs. METHODS: Surveys of pulmonary and pulmonary/critical care fellowship program directors and recent graduates of these programs were performed to assess the current state of sleep medicine education in pulmonary training, as well as the current scope of practice of pulmonary specialists. These data were used to inform a modified Delphi process focused on developing curricular recommendations relevant to sleep medicine. RESULTS: Surveys confirmed that pulmonary medicine specialists are often responsible for the diagnosis and treatment of a number of sleep conditions, including several that are not traditionally considered related to respiratory medicine. Through five rounds of voting, the panel crafted a list of 52 curricular competencies relevant to sleep medicine for recommended inclusion in pulmonary training programs. CONCLUSIONS: Practicing pulmonary specialists require a broad knowledge of sleep medicine to provide appropriate care to patients they will be expected to manage. Training program directors may use the list of competencies as a framework to ensure adequate mastery of important content by graduating fellows.