Edward F. Haponik

Weight Loss in Mildly to Moderately Obese Patients with Obstructive Sleep Apnea

The therapeutic effects of weight loss were evaluated in 15 hypersomnolent patients with moderately severe obstructive sleep apnea. As patients decreased their body weight from 106.2 +/- 7.3 kg (mean +/- SE) to 96.6 +/- 5.9 kg, apnea frequency fell from 55.0 +/- 7.5 to 29.2 +/- 7.1 episodes/h (p less than 0.01) in non-rapid-eye-movement sleep with an associated significant decline in the mean oxyhemoglobin saturation during the remaining episodes of sleep apnea from 11.9 +/- 2.4% to 7.9 +/- 1.9% (p less than 0.02). Sleep patterns also improved, with a reduction in stage I sleep from 40.2 +/- 7.3% to 23.5 +/- 4.8% (p less than 0.01), and a rise in stage II sleep from 37.3 +/- 7.0% to 49.4 +/- 4.6% (p less than 0.03). In the 9 patients with the most marked fall in apnea frequency, the tendency toward daytime hypersomnolence was decreased (p less than 0.05). No significant changes in sleep patterns occurred in 8 age- and weight-matched control patients who did not lose weight. Moderate weight loss alone can alleviate sleep apnea, improve sleep architecture, and decrease daytime hypersomnolence.

Continuous mechanical turning of intensive care unit patients shortens length of stay in some diagnostic-related groups

Periodic changing of body position is a commonly used, generally accepted modality of intensive care unit (ICU) patient care, but the optimum frequency for turning has not been established. In order to evaluate the effect of continuous turning, 86 patients were randomized to either continuous turning on a Kinetic Treatment Table (KTT) or routine turning on conventional beds every two hours by the nursing staff. Although overall ICU mortality, length of stay, APACHE-II score, duration of mechanical ventilatory management, and incidence of nosocomial pneumonia were similar in the two groups, significant differences occurred in certain subsets of patients: continously turned patients with sepsis and pneumonia had a 3.48-day shorter adjusted length of ICU stay compared with controls (P < .001). Chronic obstructive pulmonary disease patients on the KTT also required 6.84 fewer days (P < .001) in the ICU and 4.6 days less of mechanical ventilation (P < .001) than controls and had a lower final APACHE-II score. These data suggest that continuous turning on a mechanical platform shortens the requirements for length of stay and assisted ventilation in certain critically ill patients, thereby providing a major reduction in the financial costs of medical care.

Cryptogenic Hemoptysis: Clinical Features, Bronchoscopic Findings, and Natural History in 67 Patients

We reviewed the clinical outcome of 67 patients with hemoptysis and a normal or nonlocalizing chest roentgenogram and nondiagnostic fiberoptic bronchoscopic examination. During a 38 +/- 22 (SD) month period after bronchoscopy, 57 (85%) patients remained well without evidence of active tuberculosis or overlooked bronchogenic carcinoma, and 9 patients died of nonpulmonary conditions. One patient developed bronchogenic carcinoma 20 months after bronchoscopy and resolution of symptoms. Hemoptysis had resolved completely before hospital discharge in 38 (57%) patients, within 6 months in 60 (90%), and recurred in only 3. Five patients (7.5%) had intermittent episodes of bleeding for more than 1 year. Fiberoptic bronchoscopy effectively excludes specific underlying causes of hemoptysis in the setting of a normal chest roentgenogram. The prognosis for patients with cryptogenic hemoptysis is generally good, usually with resolution of bleeding within 6 months of evaluation.

Hemodynamic changes in human anaphylaxis

Human anaphylactic reactions are usually unexpected and catastrophic. Therefore, opportunities to record the physiologic changes that occur are uncommon. A patient is described who experienced an anaphylactic reaction to a penicillin drug while being monitored in an intensive care unit for ischemic heart disease. Hemodynamic monitoring indicated that the decrease in cardiac output was most likely due to a decrease in venous return. In addition, this patients previous reactions to other penicillins demonstrated that variations in the clinical manifestations of systemic anaphylaxis can occur within the same person.

Herpes simplex virus 1 pneumonia : Patterns on CT scans and conventional chest radiographs

PURPOSE The goal of our study was to describe the herpes simplex virus type 1 (HSV 1) pneumonia patterns on CT scans and chest radiographs. METHOD We retrospectively reviewed clinical records and chest radiographs of 24 patients with HSV 1 pneumonia and 10 with pneumonia from combined HSV and mixed flora infection. We also reviewed CT scans available for eight patients with HSV pneumonia and four with mixed pneumonia. RESULTS CT scans of eight patients with HSV pneumonia demonstrated multifocal segmental and subsegmental ground-glass opacities (n = 8), additional focal areas of consolidation (n = 6), scattered distribution (n = 6), and pleural effusions (n = 7). Chest radiographs (23 patients) showed patchy segmental and subsegmental ground-glass opacities and consolidation (n = 23), scattered distribution (n = 20), and pleural effusions (n = 12). Radiographic patterns for isolated HSV pneumonia and mixed flora pneumonia were not significantly different. CONCLUSION With a growing population of at-risk immunosuppressed patients, it is important to recognize CT and chest radiography patterns consistent with, although nonspecific for, HSV 1 pneumonia.

Pulse Oximetry Monitoring outside the Intensive Care Unit: Progress or Problem?

OBJECTIVE To evaluate the use of continuous pulse oximetry monitoring in general care units. DESIGN Hemoglobin oxygen saturation data collected prospectively by use of pulse oximetry with concurrent review of the medical record. SETTING General medical-surgical nursing units in a large, tertiary care university hospital. PATIENTS Forty patients on two nursing units monitored with continuous, bedside pulse oximetry at the request of their primary physicians. MEASUREMENTS All patients had continuous pulse oximetry monitoring. A research associate visited the bedside two or three times daily and recorded saturation compared with time data from the previous 8.75 hours. Patients were studied for 36 hours or until pulse oximetry monitoring was discontinued. Episodes of desaturation were counted. Patient charts were reviewed for documentation of desaturation in either nursing or physician notes. Orders adjusting oxygen therapy or other respiratory therapy within 12 hours of any desaturation episode were also recorded. MAIN RESULTS Thirty of the 40 patients (75%) had at least one episode of desaturation to less than 90%; 23 (58%) had at least one episode to less than 85%. Desaturation episodes were documented in nursing notes for only 33% of those patients who desaturated to less than 90% and in physician notes in only 7% of cases. Changes in respiratory therapy were ordered in 20% of patients who desaturated to less than 90% and in only 26% who desaturated to less than 85%. CONCLUSIONS Despite their repeated occurrence, episodes of hypoxemia were rarely documented in either nursing or physician notes. Further, even in patients who had episodic desaturation, pulse oximetry monitoring had little effect on changes in physician-directed respiratory care.

Bronchoscopically Guided Management of Ventilator-Associated Pneumonia in Trauma Patients

Abstract:The ideal approach to diagnosis and management of patients with ventilator-associated pneumonia (VAP) has not been defined. Trauma patients with suspected VAP underwent bronchoscopy for collection of quantitative bacterial cultures and were randomized to receive either prompt empiric broad-

Conventional and endobronchial ultrasound-guided transbronchial needle aspiration: complementary procedures.

Objective The diagnosis of mediastinal and hilar lymphadenopathy and staging lung cancer with endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) are on the rise. Most reports have demonstrated high yields with EBUS-TBNA and superiority of this procedure over conventional TBNA (cTBNA), but the relative roles of these procedures remain undefined. We present a comprehensive comparison of EBUS-TBNA to cTBNA. Methods We reviewed all of the bronchoscopies performed at our medical center from January 2009 through December 2010. We collected data on 82 EBUS-TBNAs and 209 cTBNAs performed. A cost analysis was subsequently performed. Results EBUS-TBNA was performed more often in patients with known prior cancer and suspicion of recurrence or staging compared with cTBNA (42% vs 18%, P < 0.001). cTBNA was more likely to be performed in patients suspected of having malignancy and needing diagnostic specimens (70% vs 46%, P = 0.009). The overall yield in which a diagnostic specimen or lymphoid tissue was obtained was not different in each group: EBUS 84% vs cTBNA 86% (P = 0.75). The cancer yield was 57% in cTBNAs compared with 44% in EBUS-TBNAs (P < 0.0001), with EBUS-TBNA more often targeting smaller nodes (mean 15 ± 7 mm vs 21 ± 11 mm; P < 0.0001) and paratracheal sites (67% vs 49%, P = 0.003). Per-procedure cost using a Medicare scale was higher for EBUS than it was for cTBNA (

Sedation for Bronchoscopy and Complications in Obese Patients

1195 vs

Bronchoscopy in the Diagnosis of Wegener Granulomatosis

808; P < 0.001). Conclusions EBUS-TBNA and cTBNA are complementary bronchoscopic procedures, and the appropriate diagnostic modality can be selected in a cost-effective manner based upon the primary indication for TBNA, lymph node size, and lymph node location.