Vidya Krishnan

Sleep Quality and Health-Related Quality of Life in Idiopathic Pulmonary Fibrosis

BACKGROUND Idiopathic pulmonary fibrosis (IPF) is a progressive disorder resulting in irreversible scarring of the lung parenchyma. Although fatigue is a prominent symptom for patients with IPF, little is known about sleep quality in patients with IPF. METHODS In this cross-sectional study of 41 patients with IPF from a prospectively designed cohort, we ascertained sleep quality by means of the Pittsburgh sleep quality index (PSQI) and the Epworth sleepiness scale. Health status, baseline demographics, and physiologic parameters were also assessed. RESULTS Patients with IPF reported extremely poor sleep quality and high frequency of daytime sleepiness, which differs significantly from normal control populations. Further, poor sleep quality was not associated with body mass index, age, gender, or lung function. This population also demonstrated extremely poor health status in a number of domains, including physical function and vitality. Poor sleep quality (by the global PSQI) was significantly associated with decreased quality of life (QOL) in several domains, including role of physical function (r = - 0.58, p = 0.001), vitality (r = - 0.43, p = 0.015), and role of emotions (r = - 0.40, p = 0.023). CONCLUSIONS Poor sleep quality is extremely common in patients with IPF and is not predicted by variables traditionally associated with sleep-disordered breathing. Further, poor sleep quality is associated with poor QOL. These findings suggest that systematic evaluation of the cause of poor sleep quality in IPF is merited.

An evaluation of a titration strategy for prescription of oral appliances for obstructive sleep apnea

BACKGROUND Oral appliances (OAs) are first-line therapy for mild-to-moderate obstructive sleep apnea (OSA) and are being used with increasing frequency. Additionally, best practice of OA titration is unknown. We describe the experience of patients treated with an OA, identify factors that predict treatment success with an OA, and offer a protocol for OA titration. METHODS We retrospectively studied patients seen in a dental sleep clinic between 2002 and 2006. Patients selected for OA treatment underwent baseline polysomnography, were individually fit with an OA, and were instructed to titrate it at home until symptom resolution or discomfort. During follow-up polysomnography, additional titration was performed as needed. Primary outcome was successful treatment, defined as apnea-hypopnea index (AHI) <10 events per hour and AHI decrease at least 50% from baseline. Logistic regression models were created to identify associations between patient characteristics and successful treatment. Overall differences in AHI at baseline, after home titration, and after final titration were compared using Kruskal-Wallis test, and post hoc comparisons were performed with sign tests, with Bonferroni corrections. RESULTS Of 57 subjects treated with an OA, 37 subjects (64.9%) were successfully treated with OA therapy. Of the 49 subjects for whom data were available for AHI after home titration, 27 subjects (55%) achieved successful treatment of OSA by self-titration, without need for further titration during follow-up polysomnography. CONCLUSIONS A majority of subjects, regardless of OSA severity, are successfully treated with an OA. Men and younger patients were found to be the best responders. The titration protocol for an OA offers a beneficial initial step in the treatment of OSA.

Interstitial lung disease and sleep: What is known?

OBJECTIVES Pulmonary fibrosis (PF), a group of disorders characterized by progressive scarring of the lung parenchyma, affects over 500,000 Americans. Fatigue is a common and frequently disabling symptom in PF. We have previously described poor subjective sleep quality in this patient population. We sought to ascertain what is known regarding sleep in PF. METHODS We reviewed the English language literature for reports on sleep and sleep disorders in patients with PF. RESULTS The existing literature is small and heterogeneous with regard to inclusion criteria. There are a number of distinctive changes in sleep architecture associated with PF including decreased REM sleep and increased sleep fragmentation. In addition, there is suggestion of possible sleep disturbances in this population including OSA, although the frequency of such sleep abnormalities as well as predictors of these abnormalities remain uncertain. CONCLUSIONS There is significant need for larger studies characterizing sleep in patients with defined PF. These studies are particularly critical given the limited options for therapy in patients with PF and the impact of fatigue in this disorder.

Self-Reported Sleep and Breathing Disturbances in Joubert Syndrome

Joubert syndrome is a rare autosomal recessive disease characterized by malformations of the cerebellar vermis, hypotonia, developmental delay, and respiratory variability. Because little is known about sleep and ventilatory dysregulation in this patient population, a questionnaire was distributed at the Joubert Syndrome and Related Disorders Foundation Conference. This questionnaire addressed respiratory and sleep abnormalities, and included the Pediatric Sleep Questionnaire. Parents or proxies completed questionnaires for patients unable to do so themselves because of young age or neurologic problems. Twenty surveys were collected. The median age was 8.3 years, and 45% were female. Seven patients (35%) reported existing episodic tachypnea, four (20%) reported apnea, and three (15%) reported both. Snoring was reported by 10 patients (50%), of whom four snored nightly and five had coexisting daytime tachypnea. Six of 14 (43%) Pediatric Sleep Questionnaire responders had scores suggestive of sleep-related breathing disorder. These results suggest that episodic tachypnea, apnea, snoring, and Pediatric Sleep Questionnaire scores suggestive of sleep-related breathing disorder are common in Joubert syndrome. Early detection and improved understanding of sleep and breathing abnormalities may contribute to improved outcomes for patients with Joubert syndrome.

Upper Airway Obstruction in Snoring and Upper Airway Resistance Syndrome

Treatment options for snoring and upper airway resistance syndrome are hampered by either low compliance or low efficacy. Therefore, refinements in these therapeutic strategies are needed. The unde

The economic burden of medical care in general and sleep apnea syndrome in particular

Healthcare spending in the U.S. has been growing steadily for the last 30 years, at a rate 2% faster than the rest of the economy. The rising costs of healthcare have had its toll on individuals’ and the nation’s finances. Nearly a half-million people file for bankruptcy every year because of high medical costs. In 2007, the total U.S. healthcare bill came to

Legal Issues Encountered When Treating the Patient With a Sleep Disorder

2.3 trillion—more than was spent on food in the same year. Despite this relatively high level of spending, the U.S. does not appear to provide substantially greater health resources to its citizens, or achieve substantially better health benchmarks, compared to other developed countries [1]. As has been clear for the last 10 years, it is high time to reform our healthcare delivery system, to make it more effective and efficient. Systematic economic analyses of healthcare delivery are and will be a valuable tool in reshaping our healthcare system. Alongside research that provides the evidence to base medical decision-making should be the research that determines the cost impact of the medical decisions. Many of our current healthcare policies and practices in medicine are guided by consensus opinion, instead of informed economic analyses. Such analyses require data on the scope, the consequences, and the costs of a medical disorder. Obstructive sleep apnea (OSA) is a disorder that has been increasingly identified as one that is highly prevalent, has significant impact on quality of life, is a risk factor for multiple co-morbid conditions and increased mortality, and is relatively simple to treat. Our imperative in the Sleep Medicine community is to convince policy makers that allocating resources to the diagnosis and treatment of OSA will have a substantial positive impact, both on medical outcomes and overall medical costs [2]. Treatment of sleep apnea syndrome (SAS), defined as OSA with clinical sleepiness, is both economical and effective. A number of studies have supported the economic benefits of treating SAS, particularly when comparing the incremental costs of treatment with CPAP per quality adjusted life years. When quality of life, costs of therapy, and motor vehicle outcomes are considered, CPAP therapy for patients with SAS is attractive for both economics and the health benefits [3, 4]. These studies do not address the potential benefits of future medical cost savings due to improved health status and reduction of co-morbidities. The economical benefits of CPAP may prove to be even more advantageous in subsets of patients who may be more vulnerable to the complications of SAS. While current medical literature justifies the treatment of all patients with SAS, limited healthcare resources may be best allocated to the subsets of patients that may benefit most from the diagnosis and treatment. Patients with obstructive lung disease, such as chronic obstructive pulmonary disease (COPD) and asthma, may be disproportionately affected by the presence of SAS. Patients with concomitant COPD and SAS have been shown to have more frequent nocturnal desaturations and sleep fragmentation [5]. In patients with severe asthma and OSA, treatment of the OSA with CPAP has been shown to significantly improve nocturnal asthma symptoms, also suggesting an interaction between the two disorders [6, 7]. There is sufficient reason to believe that the presence of SAS in patients with obstructive lung disease may worsen health status and increase the healthcare needs of these

Necrotizing epiglottitis treated with early surgical debridement: A case report

As our understanding of sleep medicine grows, so does our obligation to protect patients and society from the potential harms of sleep disorders. Harm to self and others can take the form of violent behaviors during sleep or from sleep arousals, or from errors in judgment and motor skills due to excessive daytime sleepiness. Motor vehicle accidents and industrial accidents represent the majority of deaths and injuries due to sleep disorders. Errors in judgment and mental capacity can also lead to significant problems in terms of financial costs to businesses, inefficiencies in the workplace, and harm to others (as in the case of medical errors). Sleepiness can be so debilitating to an individual that he or she may qualify for disability compensation. The sleep specialist plays three basic roles in the interaction between the medical and legal fields: the educator, the medical examiner, and the expert witness. The education of the public, court officials, and patients is necessary to increase awareness of sleep disorders and their risks. The medical examination of the patient and subsequent treatment of the sleep disorder can help to minimize the risks of sleep disorders. Finally, if necessary, the sleep specialist may be called upon to provide expert testimony about the medical evidence provided and the likelihood that a sleep disorder contributed to an alleged criminal act.

Epidemiologic Concepts and Statistics in Clinical Decision Making

OBJECTIVE Necrotizing supraglottitis is a rare but potentially morbid infection most often seen in immunocompromised patients. All reported cases have utilized intravenous antibiotic therapy as the mainstay of treatment and many have had associated morbidities. METHODS We describe a case of a 50-year-old previously healthy female who presented with necrotizing epiglottis and was treated with immediate surgical debridement followed by directed antibiotic therapy. RESULTS Our patient rapidly recovered with no further invasive interventions. On follow up she had no further complications or functional deficits. CONCLUSIONS Although uncommon, providers should be aware of the potential benefits of early debridement when treating patients with similar pathology. Early surgical intervention should be considered to avoid local tissue loss, airway interventions, and long-term sequelae.

What’s in a Name? Factors Associated with Documentation and Evaluation of Incidental Pulmonary Nodules

Interpreting a clinical study requires skills in identifying a study question, understanding the background leading to the study question, interpreting study design, and data analysis. A good clinical study clearly identifies the study hypotheses to be tested. The goal here is to present material by which the processing of information and its integration into clinical practice, a skill that must be developed in a structured and comprehensive fashion.