La ventiloterapia non invasiva nel trattamento dell'insufficienza respiratoria acuta: indicazioni controverse

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Determinants of Sleepiness at Wheel and Missing Accidents in Patients With Obstructive Sleep Apnea

Study Objectives: Motor-vehicle crashes are frequent in untreated OSA patients but there is still uncertainty on prevalence as well as physiological or clinical determinants of sleepiness at the wheel (SW) in OSA patients. We assessed determinants of SW or sleepiness related near-miss car accident (NMA) in a group of non-professional drivers with OSA. Methods: A 237 consecutive, treatment-naïve PSG-diagnosed OSA patients (161 males, 53.1 ± 12.6 years) were enrolled. Self-reported SW was assessed by positive answer to the question, “Have you had episodes of falling asleep while driving or episodes of drowsiness at wheel that could interfere with your driving skill in the last year?” Occurrence of NMA in the last 3 years was also individually recorded. Habitual self-reported average sleep time was collected. Results: SW was found in 41.3% of patients but one-quarter of patients with SW did not report excessive daytime sleepiness. Predictors of SW were the following subjective factors: Epworth sleepiness scale score (ESS-OR 1.26; IC 1.1–1.4; p < 0.0001), depressive symptoms (BDI-OR 1.2; IC 1.06–1.18; p < 0.0001) and level of risk exposure (annual mileage-OR 1.9; IC 1.15–3.1; p = 0.007). NMAs were reported by 9.7% of patients, but more frequently by SW+ than SW– (22.4% vs. 0.7%; χ2 31, p < 0.0001). The occurrence of NMAs was significantly associated to ESS, BDI, habitual sleep duration and ODI (R2 = 0.41). Conclusion: SW is not predicted by severity of OSA. Evaluation of risk exposure, assessment of depressive symptoms, and reported NMA should be included in the clinical evaluation, particularly in patients with reduced habitual sleep time and severe nocturnal hypoxia

Sleep apnea risk in subjects with asthma with or without comorbid rhinitis

BACKGROUND: As many as 80% of patients with asthma suffer from allergic rhinitis (AR), and rhinitis symptoms are associated with sleep complaints The aim of this cross-sectional study was to assess the prevalence of obstructive sleep apnea syndrome risk in patients with asthma and to explore the association between comorbid rhinitis and obstructive sleep apnea syndrome risk. METHODS: Subjects with asthma were recruited by general practitioners during a control visit. Physicians compiled a questionnaire that assessed the presence of AR according to ARIA (Allergic Rhinitis and Its Impact on Asthma) guidelines and factors influencing the risk of obstructive sleep apnea syndrome (gastroesophageal reflux disease, obesity, smoking). Subjects completed a questionnaire evaluating the presence and severity of AR and the STOP-BANG questionnaire (snoring, tiredness during daytime, observed apnea, high blood pressure, body mass index, age, neck circumference, gender), a validated screening method to identify obstructive sleep apnea syndrome risk. Physicians were blinded to the subjects\u2019 questionnaires, ensuring objectivity of the method. RESULTS: The analyses were conducted on 1,941 subjects (males 58%, mean age 48.2 \ub1 15.2 y): 740 with asthma alone and 1,201 with asthma and AR. STOP-BANG revealed that 52.6% of the subjects were at increased risk of obstructive sleep apnea syndrome: 47.3% of subjects with asthma alone and 55.9% of patients with asthma and AR. Rhinitis was associated with a 1.44 times higher odds ratio for having obstructive sleep apnea syndrome risk. Rhinitis duration and severity were associated with obstructive sleep apnea syndrome risk, although the latter deserved greater importance. The results showed that, once a correction for each of these factors was performed, subjects with AR with an odds ratio of 1.99 were reported to be at risk of obstructive sleep apnea syndrome. CONCLUSIONS: The probable increased risk of obstructive sleep apnea syndrome is associated with the concomitant presence of rhinitis, independent of obesity and other contributors to risk of obstructive sleep apnea syndrome

The respiratory rehabilitation Maugeri network service reconfiguration after 1 year of COVID-19

As part of the Italian Health Service the respiratory ICS Maugeri network were reconfigured and several in-hospital programs were suspended to be substituted by workforce and facilities reorganization for acute and post-acute COVID-19 care need. The present review shows the time course variation of respiratory ICS network in terms of admissions diagnosis and outcomes. A comparative review of the admissions and outcome measures data (anthropometric, admission diagnosis, provenience, comorbidities, disability, symptoms, effort tolerance, disease impact, length of stay and discharge destinations) over 1 year period (March 2020-March 2021) was undertaken and compared to retrospective data from a corresponding 1 year (March 2019-March 2020) period to determine the impact of the network relocation on the delivery of pulmonary specialist rehabilitation to patients with complex needs during the pandemic episode. One of the changes implemented at the respiratory Maugeri network was the relocation of the Pulmonary Rehabilitation units from its 351 beds base to a repurposed 247 beds and a reduction in total number of admitted patients (n=3912 in pre-COVID time; n=2089 in post-COVID time). All respiratory diagnosis, except COVID sequelae, decreased (chronic respiratory failure-CRF, COPD, obstructive sleep apnoea syndrome-OSAS, interstitial lung disease-ILD, tracheostomized patients and other mixed diseases decreased of 734, 705, 157, 87, 79 and 326 units, respectively). During the pandemic time, 265 post COVID sequelae with CRF were admitted for rehabilitation (12.62%), percentage of patients coming from acute hospital increased, LOS and NIV use remained stable while CPAP indication decreased. Disease impact, dyspnoea and effort tolerance as their improvements after rehabilitation, were similar in the two periods. Only baseline disability, expressed by Barthel index, seems higher in the 2 observation time as its improvement. Hospital deaths and transfers to acute hospitals were higher during pandemic crisis while home destination decreased. This review demonstrated impact of coronavirus pandemic situation, specifically the relocation of the respiratory inpatient rehabilitation wards in a huge Italian network

SAS CARE 1: Sleep architecture changes in a cohort of patients with Ischemic Stroke/TIA.

OBJECTIVE Changes in sleep architecture following ischemic stroke have been poorly investigated. Our objective was to explore changes of sleep structure in patients with ischemic stroke or transient ischemic attack in order to verify a possible predictive value of sleep with respect to clinical outcome. METHODS Patients recruited in the prospective SAS-CARE study received two polysomnographies (PSG) in the acute and chronic phases after stroke/TIA. Sleep parameters were compared between the two time-points and matched with a non-stroke population randomly selected from the HypnoLaus cohort. RESULTS Of the 169 patients investigated with PSG in the acute phase, 104 were again studied 3 months after stroke symptom onset and compared with 162 controls. The acute phase of stroke/TIA was associated with sleep disruption, which significantly improved in the chronic phase, but remained worse than controls (total sleep time improve from 318.8 ± 90.8 to 348.4 ± 81.5 min, compared to 388.2 ± 71.3 in controls, sleep latency from 49.9 ± 58.4 to 27.9 min, compared to 20.2 ± 22 in controls, sleep efficiency from 58.2 ± 18.1% to 27.9 ± 36.4 min, compared to 83.4 ± 10.3% in controls, wakefulness after sleep onset percentage from 36.5 ± 17.3 to 29.3 ± 15.6, compared to 13.2 ± 9.2 in controls). The percentage of REM sleep was negatively associated with stroke severity, whereas stroke topography did not correlate with sleep parameters. CONCLUSIONS This study confirmed a severe sleep disruption in the acute phase of stroke. Although a significant improvement of sleep quality was observed during the three months after stroke, sleep architecture did not normalize. In particular, sleep efficiency and REM sleep seem to be particularly affected by stroke in the acute phase, with a relative preservation of NREM sleep. We suggest that these sleep architecture changes represent a persistent marker of brain damage due to stroke. Further studies are needed to assess the relationship with stroke topographic and outcome

Persistence of the effects of the covid-19 lockdown on sleep: A longitudinal study

The effects of the COVID-19 pandemic on sleep have been widely documented, but longitudinal evaluations during different phases of the "COVID-19 era" are needed to disentangle the specific consequences of the r145estrictive measures on sleep variables. The aim of this study was to assess the immediate effect of the lockdown's end on sleep and sleep-related dimensions in an Italian sample, also considering the stress and depressive symptoms. We used an online survey to longitudinally collect data on sociodemographic, environmental, clinical, sleep, and sleep-related variables in two time points: during and immediately after the lockdown. The final sample included 102 participants. The large prevalence of poor sleep quality, clinically relevant pre-sleep arousal, and depressive symptoms, as well as poor sleep quality and pre-sleep arousal score observed during the lockdown, remained stable after its end. On the other hand, the prevalence of moderate-to-severe event-related stress and intrusive symptom scores exhibited a drastic reduction after the end of home confinement. Both bedtime and rise time were anticipated after the lockdown, while sleep quality exhibited only a trend of post-lockdown sleep disturbance reduction. Our findings point to a reduced stress level (specific for the intrusive symptomatology) after the end of the lockdown and persistence of sleep problems, suggesting two non-mutually exclusive hypotheses: (a) the strict restrictive measures are not the main cause of sleep problems during the pandemic and (b) home confinement induces long-lasting effects on sleep observable after its end, and a longer period of time might be needed to observe an improvement

Nutritional status and airflow obstruction: two independent contributors to CO diffusing capacity impairment in COPD

Background. The association between weight loss and Chronic Obstructive Pulmonary Disease (COPD) has been recognised from many years. Based on the evidence that nutritional status reflects metabolic disturbances in COPD, the relationship between body mass index (BMI), severity of airflow obstruction and CO diffusing capacity (DLCO), that is the functional hallmark of emphysema, is relevant to the management of COPD phenotypes. Methods. We reviewed 104 patients with COPD (82 males), aged 66±9 years (mean±SD). Height averaged 165±8 cm, weight 71±16 Kg, FEV1 50±18 (% of predicted), RV 169±49%, and DLCO 56±26%. Multiple linear regression was performed using BMI, FEV1 and RV, as explanatory variables for DLCO. Patients were also classified into four groups according to BMI ≤ 18.5 (low), > 18.5 and ≤ 25 (ideal), > 25 and ≤ 30 (overweight), > 30 (obese), and post-bronchodilator FEV1 < 50%. Using this categorisation, a two-factor analysis of variance, testing for interaction and main effects (BMI and FEV1) was performed as confirmatory analysis for the association between BMI (kg/m2), FEV1% and DLCO%. Results. FEV1 and BMI were significantly and independently associated to DLCO according to the equation: DLCO = -18.32 + 0.65·FEV1 + 1.59·BMI (R2 = 0.40, p<0.0001). The contribution of RV % to DLCO % was largely non-significant (p=0.16). A close relationship was found between BMI (kg/m2) and DLCO %, for all of the four BMI groups segregated by post-bronchodilator FEV1%, (p<.0001). No interaction was found between these two factors (p=0.30). Conclusion. Nutritional status as assessed by BMI contributes substantially to impairment of DLCO independently of the severity of airflow obstruction. This data confirms the association between emphysematous process and weight loss in advanced COPD, independent of the airflow obstruction severity

Renin Angiotensin System Blockers and Risk of Mortality in Hypertensive Patients Hospitalized for COVID-19: An Italian Registry

Background: It is uncertain whether exposure to renin\u2013angiotensin system (RAS) modifiers affects the severity of the new coronavirus disease 2019 (COVID-19) because most of the available studies are retrospective. Methods: We tested the prognostic value of exposure to RAS modifiers (either angiotensin-converting enzyme inhibitors [ACE-Is] or angiotensin receptor blockers [ARBs]) in a prospective study of hypertensive patients with COVID-19. We analyzed data from 566 patients (mean age 75 years, 54% males, 162 ACE-Is users, and 147 ARBs users) hospitalized in five Italian hospitals. The study used systematic prospective data collection according to a pre-specified protocol. All-cause mortality during hospitalization was the primary outcome. Results: Sixty-six patients died during hospitalization. Exposure to RAS modifiers was associated with a significant reduction in the risk of in-hospital mortality when compared to other BP-lowering strategies (odds ratio [OR]: 0.54, 95% confidence interval [CI]: 0.32 to 0.90, p = 0.019). Exposure to ACE-Is was not significantly associated with a reduced risk of in-hospital mortality when compared with patients not treated with RAS modifiers (OR: 0.66, 95% CI: 0.36 to 1.20, p = 0.172). Conversely, ARBs users showed a 59% lower risk of death (OR: 0.41, 95% CI: 0.20 to 0.84, p = 0.016) even after allowance for several prognostic markers, including age, oxygen saturation, occurrence of severe hypotension during hospitalization, and lymphocyte count (adjusted OR: 0.37, 95% CI: 0.17 to 0.80, p = 0.012). The discontinuation of RAS modifiers during hospitalization did not exert a significant effect (p = 0.515). Conclusions: This prospective study indicates that exposure to ARBs reduces mortality in hospitalized patients with COVID-19

Excessive Daytime Sleepiness in Obstructive Sleep Apnea Patients Treated With Continuous Positive Airway Pressure: Data From the European Sleep Apnea Database

Excessive daytime sleepiness (EDS) is a symptom of obstructive sleep apnea (OSA) that resolves under treatment with continuous positive airway pressure (CPAP). In some patients, sleepiness persists despite CPAP treatment. We retrospectively analyzed data on subjective residual EDS, assessed as an Epworth Sleepiness Scale score (ESS) &gt;10, in patients from the European Sleep Apnea Database (n = 4,853, mean age ± SD 54.8 ± 11.8 years, 26.1% females), at baseline and at the first visit (median follow-up: 5 months, interquartile range 3–13). An ESS &gt; 10 occurred in 56% of patients at baseline and in 28.2% of patients at follow-up. Residual EDS was analyzed in 2,190 patients (age: 55.1 ± 12.0 years, 26.1% females) with sleep monitoring data (median follow-up: 3 months, interquartile range 1–15). Sleep studies during CPAP use were obtained in 58% of these patients; EDS was reported by 47.2% of patients at baseline and by 30.3% at follow-up. Residual OSA, defined as an apnea–hypopnea index &gt;10/h, and insufficient CPAP adherence, defined as nightly use &lt;4 h, occurred with similar frequency in patients with and without EDS at follow-up. Prevalence of residual EDS was highest (40%) in patients with a first follow-up visit at 0–3 months, then it was 13–19% in patients with a first follow-up visit after 4 months to 2 years. The change in ESS (n = 2,190) was weakly correlated with CPAP use (R2 = 0.023, p &lt; 0.0001). Logistic regression showed that an ESS score &gt;10 at the first follow-up visit was associated directly with ESS at baseline and inversely with duration of follow-up, and CPAP use (R2 of the model: 0.417). EDS showed heterogeneity in different European countries both at baseline and at the first follow-up visit, suggesting modulation by cultural and lifestyle factors. In conclusion, residual EDS in CPAP-treated OSA occurred in approximately one in four patients at follow-up; its prevalence was highest (40%) in the first 3 months of treatment and subsequently decreased. The finding of residual EDS in a significant percentage of optimally treated OSA patients suggests that wake-promoting agents may be useful, but their indication should be evaluated after at least 3 months of treatment