Kenneth R. Casey

The treatment of central sleep apnea syndromes in adults: practice parameters with an evidence-based literature review and meta-analyses.

The International Classification of Sleep Disorders, Second Edition (ICSD-2) distinguishes 5 subtypes of central sleep apnea syndromes (CSAS) in adults. Review of the literature suggests that there are two basic mechanisms that trigger central respiratory events: (1) post-hyperventilation central apnea, which may be triggered by a variety of clinical conditions, and (2) central apnea secondary to hypoventilation, which has been described with opioid use. The preponderance of evidence on the treatment of CSAS supports the use of continuous positive airway pressure (CPAP). Much of the evidence comes from investigations on CSAS related to congestive heart failure (CHF), but other subtypes of CSAS appear to respond to CPAP as well. Limited evidence is available to support alternative therapies in CSAS subtypes. The recommendations for treatment of CSAS are summarized as follows: CPAP therapy targeted to normalize the apnea-hypopnea index (AHI) is indicated for the initial treatment of CSAS related to CHF. (STANDARD)Nocturnal oxygen therapy is indicated for the treatment of CSAS related to CHF. (STANDARD)Adaptive Servo-Ventilation (ASV) targeted to normalize the apnea-hypopnea index (AHI) is indicated for the treatment of CSAS related to CHF. (STANDARD)BPAP therapy in a spontaneous timed (ST) mode targeted to normalize the apnea-hypopnea index (AHI) may be considered for the treatment of CSAS related to CHF only if there is no response to adequate trials of CPAP, ASV, and oxygen therapies. (OPTION)The following therapies have limited supporting evidence but may be considered for the treatment of CSAS related to CHF after optimization of standard medical therapy, if PAP therapy is not tolerated, and if accompanied by close clinical follow-up: acetazolamide and theophylline. (OPTION)Positive airway pressure therapy may be considered for the treatment of primary CSAS. (OPTION)Acetazolamide has limited supporting evidence but may be considered for the treatment of primary CSAS. (OPTION)The use of zolpidem and triazolam may be considered for the treatment of primary CSAS only if the patient does not have underlying risk factors for respiratory depression. (OPTION)The following possible treatment options for CSAS related to end-stage renal disease may be considered: CPAP, supplemental oxygen, bicarbonate buffer use during dialysis, and nocturnal dialysis. (OPTION) .

The treatment of restless legs syndrome and periodic limb movement disorder in adults - An update for 2012: Practice parameters with an evidence-based systematic review and meta-analyses

A systematic literature review and meta-analyses (where appropriate) were performed to update the previous AASM practice parameters on the treatments, both dopaminergic and other, of RLS and PLMD. A considerable amount of literature has been published since these previous reviews were performed, necessitating an update of the corresponding practice parameters. Therapies with a STANDARD level of recommendation include pramipexole and ropinirole. Therapies with a GUIDELINE level of recommendation include levodopa with dopa decarboxylase inhibitor, opioids, gabapentin enacarbil, and cabergoline (which has additional caveats for use). Therapies with an OPTION level of recommendation include carbamazepine, gabapentin, pregabalin, clonidine, and for patients with low ferritin levels, iron supplementation. The committee recommends a STANDARD AGAINST the use of pergolide because of the risks of heart valve damage. Therapies for RLS secondary to ESRD, neuropathy, and superficial venous insufficiency are discussed. Lastly, therapies for PLMD are reviewed. However, it should be mentioned that because PLMD therapy typically mimics RLS therapy, the primary focus of this review is therapy for idiopathic RLS.

Update to the AASM Clinical Practice Guideline: “The Treatment of Restless Legs Syndrome and Periodic Limb Movement Disorder in Adults—An Update for 2012: Practice Parameters with an Evidence-Based Systematic Review and Meta-Analyses”

In January 2012, the AASM Board of Directors approved the Standards of Practice paper titled “The Treatment of Restless Legs Syndrome and Periodic Limb Movement Disorder in Adults - An Update for 2012: Practice Parameters with an Evidence-Based Systematic Review and Meta-Analyses.” The 2012 update included a new drug not reviewed in the previous 2004 AASM guidelines for the treatment of Restless Legs Syndrome (RLS) and Periodic Limb Movement Disorder (PLMD) – rotigotine. Rotigotine was originally approved by the US Food and Drug Administration (FDA) for the treatment of signs and symptoms associated with early stage idiopathic Parkinson’s disease. Additionally, rotigotine had been shown in clinical trials to be effective for the treatment of moderate-to-severe RLS. In 2008, rotigotine was withdrawn from the US market due to concerns about inconsistent absorption from the patch; therefore, rotigotine was not an FDA-approved treatment option for RLS or PLMD when the 2012 update was accepted for publication. Thus, despite high level evidence supporting the efficacy of this drug for the treatment of moderate-to-severe RLS, the Standards of Practice Committee (SPC) made no recommendation regarding the use of rotigotine in the setting of RLS. The issue of drug absorption was subsequently resolved by the manufacturer, and the new formulation of rotigotine received FDA approval in April 2012. Rotigotine is currently FDA approved both for the treatment of signs and symptoms associ

Practice Parameters for the Non-Respiratory Indications for Polysomnography and Multiple Sleep Latency Testing for Children

BACKGROUND Although a level 1 nocturnal polysomnogram (PSG) is often used to evaluate children with non-respiratory sleep disorders, there are no published evidence-based practice parameters focused on the pediatric age group. In this report, we present practice parameters for the indications of polysomnography and the multiple sleep latency test (MSLT) in the assessment of non-respiratory sleep disorders in children. These practice parameters were reviewed and approved by the Board of Directors of the American Academy of Sleep Medicine (AASM). METHODS A task force of content experts was appointed by the AASM to review the literature and grade the evidence according to the American Academy of Neurology grading system. RECOMMENDATIONS FOR PSG AND MSLT USE PSG is indicated for children suspected of having periodic limb movement disorder (PLMD) for diagnosing PLMD. (STANDARD)The MSLT, preceded by nocturnal PSG, is indicated in children as part of the evaluation for suspected narcolepsy. (STANDARD)Children with frequent NREM parasomnias, epilepsy, or nocturnal enuresis should be clinically screened for the presence of comorbid sleep disorders and polysomnography should be performed if there is a suspicion for sleep-disordered breathing or periodic limb movement disorder. (GUIDELINE)The MSLT, preceded by nocturnal PSG, is indicated in children suspected of having hypersomnia from causes other than narcolepsy to assess excessive sleepiness and to aid in differentiation from narcolepsy. (OPTION)The polysomnogram using an expanded EEG montage is indicated in children to confirm the diagnosis of an atypical or potentially injurious parasomnia or differentiate a parasomnia from sleep-related epilepsy (OPTION)Polysomnography is indicated in children suspected of having restless legs syndrome (RLS) who require supportive data for diagnosing RLS. (OPTION) RECOMMENDATIONS AGAINST PSG USE: Polysomnography is not routinely indicated for evaluation of children with sleep-related bruxism. (STANDARD) CONCLUSIONS: The nocturnal polysomnogram and MSLT are useful clinical tools for evaluating pediatric non-respiratory sleep disorders when integrated with the clinical evaluation.

Health implications of natural fibrous zeolites for the intermountain west

INTRODUCTION Fibrous zeolites have recently been implicated in an endemic outbreak of malignant pleural mesothelioma in several villages in Cappadocia in central Tur- key (Baris et al., 1979; Lilis, 1981). The possible association between fibrous zeolites and mesothelioma and the potential biological activity of fibrous erionite from the United States are under active investigation. The zeolite minerals com- prise a group of over forty hydrated aluminum silicates. More than 300 probable deposits of the various natural zeolites are located in 25 states in the United States. Reserves of perhaps 10 trillion tons are present in the western United States; about 120 million tons are deposited near the surface (Sheppard, 1975). Several zeolites, including erionite and mordenite, may occur with a fibrous habit. Fibrous erionite is found in several well-defined deposits in Arizona, Nevada, Oregon, and Utah, where it occurs as thin, pure beds within sedimentary tuff sequences, or as outcrops in desert valleys of the Intermountain region. MINERALOGY Zeolites were first recognized as a new group of minerals by Baron Cronstedt with the discovery of stilbite in 1756 (Papke, 1972). Because of the unique quality of intumescence, zeolites were aptly named from the Greek zein and lithos mean- ing “boiling stones.” Zeolites are a group of crystalline sedimentary minerals’ that contain alkali or alkaline-earth elements in a hydrated aluminum silicate structure. They have an open, three-dimensional framework composed of silicon and aluminum tetrahedra (Flanigan, 1959). The central silicon or aluminum in each tetrahedron is sur- rounded by four oxygen atoms each of which is shared by two tetrahedra in a honeycombed, crystalline lattice with cavities and apertures characteristic of each

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.

Revisiting Evidence-Based Guidelines: Not Such a Nightmare.

Dr. Cranston and colleagues should be commended for the thorough job they did expanding upon the foundation of the article, “Best Practice Guide for the Treatment of Nightmare Disorder in Adults.”1 The authors have 3 criticisms of the article: (1) the methodology was used inconsistently at updated time points; (2) the article was missing references that were within the search criteria and therefore not reported; and (3) the search database used was insufficient. In the following sections, these concerns are addressed.

The application of lasers in thoracic medicine and surgery

The domain of the chest physician includes components of several different organ systems. The chest surgeon, or his medical counterpart, must be well versed in diseases of the esophagus, respiratory system and cardiovascular system. In recent years, lasers have become valuable instruments for the treatment of diseases in all three of these systems. Lasers have been applied clinically in the endoscopic treatment of esophageal and tracheobronchial processes. There have been few clinical applications of lasers in cardiovascular medicine, however, there is much investigation currently in process in this area and much excitement about the potential applications on the horizon. Photodynamic therapy utilizing light activated cytoxic substances and laser light is yet another promising approach in the treatment of many forms of cancer.The domain of the chest physician includes components of several different organ systems. The chest surgeon, or his medical counterpart, must be well versed in diseases of the esophagus, respiratory system and cardiovascular system. In recent years, lasers have become valuable instruments for the treatment of diseases in all three of these systems. Lasers have been applied clinically in the endoscopic treatment of esophageal and tracheobronchial processes. There have been few clinical applications of lasers in cardiovascular medicine, however, there is much investigation currently in process in this area and much excitement about the potential applications on the horizon. Photodynamic therapy utilizing light activated cytoxic substances and laser light is yet another promising approach in the treatment of many forms of cancer.