Elizabeth C. Parsons

Red blood cell transfusion and outcomes in patients with acute lung injury, sepsis and shock

IntroductionIn this study, we sought to determine the association between red blood cell (RBC) transfusion and outcomes in patients with acute lung injury (ALI), sepsis and shock.MethodsWe performed a secondary analysis of new-onset ALI patients enrolled in the Acute Respiratory Distress Syndrome Network Fluid and Catheter Treatment Trial (2000 to 2005) who had a documented ALI risk factor of sepsis or pneumonia and met shock criteria (mean arterial pressure (MAP) < 60 mmHg or vasopressor use) within 24 hours of randomization. Using multivariable logistic regression, we examined the association between RBC transfusion and 28-day mortality after adjustment for age, sex, race, randomization arm and Acute Physiology and Chronic Health Evaluation III score. Secondary end points included 90-day mortality and ventilator-free days (VFDs). Finally, we examined these end points among the subset of subjects meeting prespecified transfusion criteria defined by five simultaneous indicators: hemoglobin < 10.2 g/dL, central or mixed venous oxygen saturation < 70%, central venous pressure ≥ 8 mmHg, MAP ≥ 65 mmHg, and vasopressor use.ResultsWe identified 285 subjects with ALI, sepsis, shock and transfusion data. Of these, 85 also met the above prespecified transfusion criteria. Fifty-three (19%) of the two hundred eighty-five subjects with shock and twenty (24%) of the subset meeting the transfusion criteria received RBC transfusion within twenty-four hours of randomization. We found no independent association between RBC transfusion and 28-day mortality (odds ratio = 1.49, 95% CI (95% confidence interval) = 0.77 to 2.90; P = 0.23) or VFDs (mean difference = -0.35, 95% CI = -4.03 to 3.32; P = 0.85). Likewise, 90-day mortality and VFDs did not differ by transfusion status. Among the subset of patients meeting the transfusion criteria, we found no independent association between transfusion and mortality or VFDs.ConclusionsIn patients with new-onset ALI, sepsis and shock, we found no independent association between RBC transfusion and mortality or VFDs. The physiological criteria did not identify patients more likely to be transfused or to benefit from transfusion.

Insomnia is associated with quality of life impairment in medical-surgical intensive care unit survivors

OBJECTIVES To examine the prevalence of insomnia and its relationship to health-related quality of life (HRQOL) post-intensive care unit (ICU). BACKGROUND The burden of post-ICU insomnia is unknown. METHODS This cross-sectional study examined data from 120 patients with an ICU stay >24 h. Pre-hospital health was assessed in-hospital. Insomnia, HRQOL and post-ICU psychiatric symptoms were assessed at 12 months post-ICU. RESULTS Over one-quarter (28%) of subjects met insomnia criteria at 12 months post-ICU. Post-ICU insomnia was independently associated with worse mental HRQOL (P < 0.01), as well as worse scores on the HRQOL sub-domains of bodily pain (P < 0.001), vitality (P < 0.05) and physical function (P < 0.05). However, these associations were no longer significant after adjusting for post-ICU psychiatric symptoms (P = 0.33). CONCLUSIONS Insomnia is common among ICU survivors. Post-ICU insomnia is significantly associated with mental HRQOL and could identify ICU survivors who may benefit from further psychiatric evaluation.

Development of a Sleep Telementorship Program for Rural Department of Veterans Affairs Primary Care Providers: Sleep Veterans Affairs Extension for Community Healthcare Outcomes.

Rationale: Primary care providers (PCPs) frequently encounter sleep complaints, especially in regions with limited specialty care access. Objectives: The U.S. Department of Veterans Affairs Extension for Community Healthcare Outcomes (VA‐ECHO) program (based on Project ECHO) has successfully provided rural PCP education in subspecialty areas, including hepatitis C. We describe the feasibility of an ECHO program for sleep medicine. Methods: ECHO creates a virtual learning community through video‐teleconferencing, combining didactics with individualized clinical case review. We invited multidisciplinary providers to attend up to 10 stand‐alone, 1‐hour sessions. Invitees completed a needs assessment, which guided curriculum development. After program completion, we examined participant characteristics and self‐reported changes in practice and comfort with managing sleep complaints. We surveyed participation barriers among invitees with low/no attendance. Measurements and Main Results: Of the 39 program participants, 38% worked in rural healthcare. Participants included nurse practitioners (26%), registered nurses (21%), and physicians (15%). Seventeen (44%) completed the summative program evaluation. Respondents anticipated practice change from the program, especially in patient education about sleep disorders (93% of respondents). Respondents reported improved comfort managing sleep complaints, especially sleep‐disordered breathing, insomnia, and sleep in post‐traumatic stress disorder (80% of respondents each). A follow‐up survey of program invitees who attended zero to two sessions reported scheduling conflicts (62%) and lack of protected time (52%) as major participation barriers. Conclusions: Participants in a pilot sleep medicine VA‐ECHO program report practice change and increased comfort managing common sleep complaints. Future work is needed to identify objective measures of return on investment and address participation barriers.

Sleep disturbance in smokers with preserved pulmonary function and with chronic obstructive pulmonary disease

Rationale: Sleep disturbance frequently affects patients with chronic obstructive pulmonary disease (COPD), and is associated with reduced quality of life and poorer outcomes. Data indicate that smokers with preserved pulmonary function have clinical symptoms similar to those meeting spirometric criteria for COPD, but little is known about the driving factors for sleep disturbance in this population of emerging interest. Objectives: To compare the magnitude and correlates of sleep disturbance between smokers with preserved pulmonary function and those with airflow obstruction. Methods: Using cross‐sectional data from the COPD Outcomes‐Based Network for Clinical Effectiveness and Research Translation multicenter registry, we identified participants clinically identified as having COPD with a smoking history of at least 20 pack‐years and either preserved pulmonary function or airflow obstruction. We quantified sleep disturbance by T‐score measured in the sleep disturbance domain of the Patient‐Reported Outcomes Information System questionnaire, and defined a minimum important difference as a T‐score difference of two points. We performed univariate and multivariable linear regression to evaluate correlates within each group. Results: We identified 100 smokers with preserved pulmonary function and 476 with airflow obstruction. The sleep disturbance T‐score was 4.1 points greater among individuals with preserved pulmonary function (95% confidence interval [CI], 2.0‐6.3). In adjusted analyses, depression symptom T‐score was associated with sleep disturbance in both groups (airflow obstruction: &bgr;, 0.61 points; 95% CI, 0.27‐0.94; preserved pulmonary function: &bgr;, 0.25 points; 95% CI, 0.12‐0.38). Of note, lower percent predicted FEV1 was associated with greater sleep disturbance among those with preserved pulmonary function (&bgr;, ‐0.19 points; 95% CI, ‐0.31 to ‐0.07), whereas higher FEV1 was associated with greater sleep disturbance among individuals with airflow obstruction (&bgr;, 0.06 points; 95% CI, 0.01‐0.10). Conclusions: Among smokers with clinically identified COPD, the severity of sleep disturbance is greater among those with preserved pulmonary function compared with those with airflow obstruction. Nonrespiratory symptoms, such as depression, were associated with sleep disturbance in both groups, whereas the relationship of sleep disturbance with FEV1 differed.

Introduction to Obstructive Sleep Apnea for the Internist

Introduction The prevalence of sleep-disordered breathing is increasing, and there are insufficient sleep medicine specialists to meet the clinical demand of caring for these patients. One way to meet this clinical need is to train primary care and internal medicine physicians to provide some of the care. However, trainees in these specialties often receive very little training on practical aspects of the management of obstructive sleep apnea (OSA). We developed an experiential workshop to address this need at our institution. Methods For approximately 60 internal medicine residents, we ran a 2.5-hour workshop consisting of two 20-minute didactic presentations to the whole audience and two 40-minute breakout sessions, led by eight facilitators. During the breakout sessions, the residents interacted with equipment such as positive airway pressure (PAP) devices and interfaces, reviewed sleep testing and PAP download reports, and participated in guided small-group discussions. Results We received 40 evaluation surveys with at least partial responses. Only 50% of respondents had received prior formal instruction on PAP devices. Both subjective and objective knowledge scores improved on the postworkshop questions compared to the preworkshop questions. Trainee comments were extremely positive, indicating that they enjoyed the format of the session. Discussion This curriculum provides an interactive educational session focused on practical aspects of OSA management relevant to primary care physicians and internists. It was well received and could be adapted to suit other time frames and other groups of learners.

A Novel Treatment for Nasolacrimal Air Regurgitation Into the Eye With CPAP: The Total Face Mask

ABSTRACT We present a patient who experienced insufflation of air under the left eyelid when using continuous positive airway pressure (CPAP) via an oronasal mask. The patient had a lacrimal stent in place for many years, which was a predisposing factor for this complication. Lacrimal stents are frequently used in the treatment of epiphora (excessive tearing) secondary to obstruction of the lacrimal drainage system. In this case, we review the pathophysiology of air regurgitation into the eye with CPAP use and methods previously described to address this rare complication. We also present a novel intervention for this rare complication, the total face mask. By additionally covering the eyes, a total face mask allows equalization of pressure on both sides of the lacrimal system. With a total face mask, our patient was able to successfully use CPAP.

Validity of a single PTSD checklist item to screen for insomnia in survivors of critical illness

Background There is no insomnia screening tool validated in intensive care unit (ICU) survivors. Objectives To examine the validity of a single item from the PTSD checklist‐Civilian version (PCL‐C) to detect insomnia by Insomnia Severity Index (ISI) Methods We performed a secondary analysis of data from a longitudinal investigation in 120 medical‐surgical ICU survivors. At 1 year post‐ICU, patients completed ISI, PCL‐C, and Medical Short‐Form 12 (SF‐12) by telephone. A single PCL‐C item rates difficulty initiating or maintaining sleep over the past month. We compared performance characteristics of this PCL‐C item to ISI‐defined insomnia (ISI ≥15). Results A score of ≥3 on the PCL‐C sleep item exhibited 91% sensitivity and 67% specificity for ISI‐defined insomnia (ISI ≥ 15), and it demonstrated construct validity by correlation to related QOL indices. Conclusions A single PCL‐C sleep item score ≥ 3 is a reasonable screen to identify insomnia symptoms in ICU survivors.

Hands-on Pulmonary Curriculum: Interactive Learning Sessions on Oxygen Delivery, Spirometry, Positive Airway Pressure Devices, Tracheostomy, and Thoracostomy Tubes

Introduction Pulmonary equipment has become ubiquitous in clinical care. Basic device troubleshooting and mechanical manipulation skills are crucial to the practicing physician yet are frequently neglected in standard pulmonary curricula. Methods We developed a hands-on pulmonary curriculum for medical residents and students, focusing on oxygen delivery, spirometry, positive airway pressure devices, thoracostomy, and tracheostomy knowledge. The curriculum, consisting of five 1-hour sessions, offers hands-on experience with basic pulmonary equipment relevant to the ICU and/or pulmonary clinic. Each session is led by a pulmonologist or critical care facilitator and designed for a learning audience of 10–15 internal medicine trainees and medical students. More than 11 sessions have been conducted since curriculum implementation. Results Voluntary, immediate, pre- and postsession surveys assessed objective subject knowledge, perceived subject understanding, and perceived effectiveness of this hands-on format versus a conventional lecture style. A total of 52 learners returned surveys. Aggregate responses demonstrated that these sessions were typically the first formal training learners had received in these subject areas. Subject knowledge and perceived level of subject understanding both improved, and respondents reported the hands-on style of teaching was more effective than conventional lecture format. Discussion Focused on practical knowledge, this pulmonary hands-on curriculum addresses a knowledge gap for medical trainees, has been enthusiastically received by trainees, and provides a useful resource for faculty wishing to teach about these devices.

Sleep Disordered Breathing in the Lung Transplant Population, a Case Report and Literature Review

Background: Patients waiting for and having received lung transplantation commonly demonstrate known risk factors for sleep disordered breathing (SDB) including central sleep apnea (CSA). However, little is known is about the prevalence or clinical implications of SDB in this patient population. Methods: We report a 61 year old man who underwent uncomplicated bilateral lung transplantation. Approximately 5 weeks post-transplant, the patient developed fatigue, somnolence, and mild intermittent confusion. Extensive cardiologic and neurologic evaluations were unrevealing regarding cause of symptoms. Diagnostic polysomnogram revealed severe central sleep apnea with a periodic respiratory pattern. Results: The patient was initiated on positive airway pressure therapy during sleep with an adaptive servoventilation device which successfully treated central sleep apnea and improved daytime symptoms. A repeat diagnostic polysomnogram performed 8 months post-transplant showed resolution of central sleep apnea. Conclusion: SDB including CSA is a poorly understood occurrence in the lung transplantation patient population that warrants clinical attention and further investigation.