Kristy A. Bauman

Home-Based Overnight Transcutaneous Capnography/Pulse Oximetry for Diagnosing Nocturnal Hypoventilation Associated With Neuromuscular Disorders

OBJECTIVE To determine the utility of home-based, unsupervised transcutaneous partial pressure of carbon dioxide (tc-Pco(2)) monitoring/oxygen saturation by pulse oximetry (Spo(2)) for detecting nocturnal hypoventilation (NH) in individuals with neuromuscular disorders. DESIGN Retrospective case series analyzed consecutively. SETTING Multidisciplinary neuromuscular respiratory failure (NMRF) clinic at an academic institution. PARTICIPANTS Subjects (N=35, 68.6% men; mean age, 46.9y) with spinal cord injury (45.7%) or other neuromuscular disorders underwent overnight tests with tc-Pco(2)/Spo(2) monitoring. Fifteen (42.9%) were using nocturnal ventilatory support, either bilevel positive airway pressure (BiPAP) or tracheostomy ventilation (TV). INTERVENTIONS A respiratory therapist brought a calibrated tc-Pco(2)/Spo(2) monitor to the patients home and provided instructions for data collection during the subjects normal sleep period. Forced vital capacity (FVC), body mass index (BMI), and exhaled end-tidal Pco(2) (ET-Pco(2)) were recorded at a clinic visit before monitoring. MAIN OUTCOME MEASURES Detection of NH (tc-Pco(2) ≥50mmHg for ≥5% of monitoring time). Data were also analyzed to determine whether nocturnal oxygen desaturation (Spo(2) ≤88% for ≥5% of monitoring time), FVC, BMI, or daytime ET-Pco(2) could predict the presence of NH. RESULTS NH was detected in 18 subjects (51.4%), including 53.3% of those using BiPAP or TV. NH was detected in 43.8% of ventilator-independent subjects with normal daytime ET-Pco(2) (present for 49.4%±31.5% [mean ± SD] of the study period), and in 75% of subjects with an elevated daytime ET-Pco(2) (present for 92.3%±8.7% of the study period). Oxygen desaturation, BMI, and FVC were poor predictors of NH. Only 3 attempted monitoring studies failed to produce acceptable results. CONCLUSIONS Home-based, unsupervised monitoring with tc-Pco(2)/Spo(2) is a useful method for diagnosing NH in NMRF.

Sleep disordered breathing in spinal cord injury: A systematic review.

Context: Spinal cord injury commonly results in neuromuscular weakness that impacts respiratory function. This would be expected to be associated with an increased likelihood of sleep-disordered breathing. Objective: (1) Understand the incidence and prevalence of sleep disordered breathing in spinal cord injury. (2) Understand the relationship between injury and patient characteristics and the incidence of sleep disordered breathing in spinal cord injury. (3) Distinguish between obstructive sleep apnea and central sleep apnea incidence in spinal cord injury. (4) Clarify the relationship between sleep disordered breathing and stroke, myocardial infarction, metabolic dysfunction, injuries, autonomic dysreflexia and spasticity incidence in persons with spinal cord injury. (5) Understand treatment tolerance and outcome in persons with spinal cord injury and sleep disordered breathing. Methods: Extensive database search including PubMed, Cochrane Library, CINAHL and Web of Science. Results: Given the current literature limitations, sleep disordered breathing as currently defined is high in patients with spinal cord injury, approaching 60% in motor complete persons with tetraplegia. Central apnea is more common in patients with tetraplegia than in patients with paraplegia. Conclusion: Early formal sleep study in patients with acute complete tetraplegia is recommended. In patients with incomplete tetraplegia and with paraplegia, the incidence of sleep-disordered breathing is significantly higher than the general population. With the lack of correlation between symptoms and SDB, formal study would be reasonable. There is insufficient evidence in the literature on the impact of treatment on morbidity, mortality and quality of life outcomes.

ICU 2020 Five Interventions to Revolutionize Quality of Care in the ICU

Intensive care units (ICUs) are an essential and unique component of modern medicine. The number of critically ill individuals, complexity of illness, and cost of care continue to increase with time. In order to meet future demands, maintain quality, and minimize medical errors, intensivists will need to look beyond traditional medical practice, seeking lessons on quality assurance from industry and aviation. Intensivists will be challenged to keep pace with rapidly advancing information technology and its diverse roles in ICU care delivery. Modern ICU quality improvement initiatives include ensuring evidence-based best practice, participation in multicenter ICU collaborations, employing state-of-the-art information technology, providing point-of-care diagnostic testing, and efficient organization of ICU care delivery. This article demonstrates that each of these initiatives has the potential to revolutionize the quality of future ICU care in the United States.

Multidisciplinary Evaluation of Patients With Suspected Lung Cancer.

Lung cancer diagnosis and treatment have evolved to require the input and expertise of multiple diverse medical and surgical specialties. The approach to lung cancer patients requires the adherence to a few principles that include thorough use of staging modalities to assure the proper treatment for each patient, and an understanding of the limitations and advantages of each of these modalities. Evidence is continuing to emerge that supports the notion that diagnostic workup and treatment of lung cancer patients is best done within the context of a multidisciplinary team devoted to this purpose.

Positive airway pressure therapy for sleep-disordered breathing confers short-term benefits to patients with spinal cord injury despite widely ranging patterns of use

Study designProspective, cohort study.ObjectivesTo evaluate the effectiveness of bi-level positive airway pressure (PAP) therapy and the patterns of use for sleep-disordered breathing (SDB) in individuals with spinal cord injury (SCI).SettingAcademic tertiary care center, USA.MethodsOverall, 91 adults with C1-T6 SCI for ≥3 months were recruited and 74 remained in the study to be evaluated for SDB and follow-up. Individuals with SDB but no nocturnal hypercapnia (NH) were prescribed auto-titrating PAP. Those with NH were prescribed PAP with volume-assured pressure support. Device downloads and overnight transcutaneous capnography were performed at 3, 6, and 12 months to quantify PAP use and effectiveness. Participants kept daily event logs, and quality of life (QOL) questionnaires were performed after 3, 6, and 12 months.ResultsOverall, 45% of 91 participants completed the study. There was great diversity among SCI patients in PAP utilization; after 3 months, 37.8% of participants used PAP for ≥70% nights and ≥240 min per night, whereas 42.2% seldom used PAP and 20% used PAP sporadically or for short periods. PAP therapy was effective in improving OSA in 89% and nocturnal hypercapnia in 77%. Higher PAP pressures predicted higher levels of device use. There were marked reductions in symptoms of autonomic dysreflexia (AD) and orthostatic hypotension as well as some improved indices of QOL.ConclusionsDespite widely diverse patterns of use, PAP therapy may have short-term benefits with regard to QOL and reducing episodes of dizziness and autonomic dysreflexia.

Acute Exacerbation of COPD: Non-invasive Positive Pressure Ventilation

Acute exacerbations of COPD complicated by hypercapnic respiratory failure are associated with significant hospital and short-term mortality. Several aspects of standard medical therapy for COPD have remained largely unchanged for years. Non-invasive positive pressure ventilation (NIPPV) has emerged as a life-saving therapy, reversing respiratory failure and preventing endotracheal intubation. NIPPV is beneficial for select COPD patients with altered mental status, those with do-not-intubate orders and for recently extubated patients at high risk of respiratory failure. In addition to standard medical therapy, in the absence of absolute contra-indication, NIPPV should be initiated for all individuals with acute hypercapnic respiratory failure due to an acute exacerbation of COPD.

Prostatic Adenocarcinoma With Hormone Exposure Related Changes in a Patient With Hepatic Cirrhosis - Value of Autopsy in a Case Report.

Hepatic cirrhosis is commonly associated with hyperestrogenism. Previous studies have reported morphologic changes in benign and malignant prostate tissue exposed to estrogen or anti-androgens. To our knowledge, histopathologic features of prostatic adenocarcinoma in patients with cirrhosis have not been well-reported. We present a case of incidental, but pathologically significant, prostatic adenocarcinoma detected on autopsy in a 67-year-old male patient with cirrhosis and spider angiomata. The morphologic and immunohistochemical features (including variable ERG expression) of the prostatic adenocarcinoma were consistent with hormone exposure related changes, suggesting that cirrhosis-induced elevated estrogen-to-testosterone ratio and exogenous hormone therapy might induce similar phenotypes.

Gender Differences in Susceptibility, Outcomes, and Pathophysiology of Sepsis

Publisher Summary Systemic inflammatory response syndrome (SIRS) is a clinical syndrome characterized by systemic inflammation and widespread tissue injury. SIRS is defined by several clinical variables including temperature > 38°C or 90 beats/min, respiratory rate > 20 breaths/min or PCO2 12 000 cells/mm3 or <4000 cells/mm3. SIRS can result from insults such as trauma, thermal injury, pancreatitis, autoimmune disorders, and surgery. When SIRS occurs as a result of infection, it is termed sepsis. Severe sepsis occurs when there is evidence of organ hypoperfusion or dysfunction including decreased urine output, altered mental status, and disseminated intravascular coagulation. Septic shock ensues if hypotension persists despite adequate volume resuscitation and vasopressors are required to achieve adequate systemic blood pressure. This chapter reviews the epidemiology and pathophysiology of sepsis, particularly as it applies to gender, and provides insights into potential mechanisms for gender differences. Both estrogen and relaxin may reduce pulmonary artery pressures and improve hemodynamics. Relaxin may also improve splanchnic blood flow and stimulate the glucocorticoid receptor leading to decreased inflammation. Testosterone, on the other hand, acts as an immune suppressant. While this data is intriguing, the pathophysiology of sepsis, however, is complicated and depends on a balance between pro- and anti-inflammatory mediators which may explain why studies examining gender differences in sepsis outcomes have reported such varying results.