Blood pressure change after treatment for obstructive sleep apnoea (OSA) with continuous positive airway pressure (CPAP)

It is unclear whether OSA is an independent risk factor for hypertension and whether CPAP treatment reduces blood pressure (BP). We conducted a randomised parallel controlled trial of 4 weeks therapeutic versus sub-therapeutic CPAP treatment (as a control) in men with OSA (Epworth Score (ESS) >10, >4% SaO2 dips >10 per hour). We measured 24-hour BP at home using the TM-2420 ambulatory BP monitoring system before and after treatment. Diary cards were used to report sleep and wake periods. BP changes with treatment were compared between groups using independent samples T-Tests. 85 patients completed the trial. Median (range), age 50 (33-73) years; Body Mass Index 33.7 (24.9-53.9); ESS 16 (10-24); SaO2 dip rate 32.1 (10.6-101.3) and similar between groups. Machine use hours CPAP per night was equivalent between therapeutic 5.4 (2.3-9) and control groups 5.5 (0.4-10). The groups had similar baseline 24 hour BP, mean (SD) therapeutic 132.7 (14.5) / 85.3 (9.5), controls 132.5 (16.6)/84.5 (9.1). Change in BP with Treatment Systolic(mmHg) Diastolic(mmHg) Overall Wake Sleep Overall Wake Sleep Therapeutic -2.4 -1.4 -5.8 -1.6 -1.9 -2.0 n=41 (1.4) (1.4) (1.8) (1.3) (1.4) (1.4) Control +1.4 +2.8 -0.4 +0.6 +1.5 -0.8 n=44 (1.3) (1.4) (1.7) (0.8) (.86) (1.3) p value <0.05 <0.05 <0.04 ns <0.05 ns Mean change (SEM) in Systolic and Diastolic BP by treatment group. Post treatment, sleep period systolic BP was also significantly different on a between groups comparison of means, therapeutic mean (SD) 118.1 (13.3) mmHg versus control 125.6 (18.4), p<0.05. These results support OSA as an independent risk factor for the elevation of blood pressure in men, and shows a blood pressure fall with CPAP treatment

Providing safe and effective pleural medicine services in the UK: An aspirational statement from UK pleural physicians

Physicians face considerable challenges in ensuring safe and effective care for patients admitted to hospital with pleural disease. While subspecialty development has driven up standards of care, this has been tempered by the resulting loss of procedural experience in general medical teams tasked with managing acute pleural disease. This review aims to define a framework though which a minimum standard of care might be implemented. This review has been written by pleural clinicians from across the UK representing all types of secondary care hospital. Its content has been formed on the basis of literature review, national guidelines, National Health Service England policy and consensus opinion following a round table discussion. Recommendations have been provided in the broad themes of procedural training, out-of-hours management and pleural service specification. Procedural competences have been defined into descriptive categories: emergency, basic, intermediate and advanced. Provision of emergency level operators at all times in all trusts is the cornerstone of out-of-hours recommendations, alongside readily available escalation pathways. A proposal for minimum standards to ensure the safe delivery of pleural medicine have been described with the aim of driving local conversations and providing a framework for service development, review and risk assessment

Effect of thoracoscopic talc poudrage vs talc slurry via chest tube on pleurodesis failure rate among patients with malignant pleural effusions: a randomized clinical trial

Importance Malignant pleural effusion (MPE) is challenging to manage. Talc pleurodesis is a common and effective treatment. There are no reliable data, however, regarding the optimal method for talc delivery, leading to differences in practice and recommendations. Objective To test the hypothesis that administration of talc poudrage during thoracoscopy with local anesthesia is more effective than talc slurry delivered via chest tube in successfully inducing pleurodesis. Design, Setting, and Participants Open-label, randomized clinical trial conducted at 17 UK hospitals. A total of 330 participants were enrolled from August 2012 to April 2018 and followed up until October 2018. Patients were eligible if they were older than 18 years, had a confirmed diagnosis of MPE, and could undergo thoracoscopy with local anesthesia. Patients were excluded if they required a thoracoscopy for diagnostic purposes or had evidence of nonexpandable lung. Interventions Patients randomized to the talc poudrage group (n = 166) received 4 g of talc poudrage during thoracoscopy while under moderate sedation, while patients randomized to the control group (n = 164) underwent bedside chest tube insertion with local anesthesia followed by administration of 4 g of sterile talc slurry. Main Outcomes and Measures The primary outcome was pleurodesis failure up to 90 days after randomization. Secondary outcomes included pleurodesis failure at 30 and 180 days; time to pleurodesis failure; number of nights spent in the hospital over 90 days; patient-reported thoracic pain and dyspnea at 7, 30, 90, and 180 days; health-related quality of life at 30, 90, and 180 days; all-cause mortality; and percentage of opacification on chest radiograph at drain removal and at 30, 90, and 180 days. Results Among 330 patients who were randomized (mean age, 68 years; 181 [55%] women), 320 (97%) were included in the primary outcome analysis. At 90 days, the pleurodesis failure rate was 36 of 161 patients (22%) in the talc poudrage group and 38 of 159 (24%) in the talc slurry group (adjusted odds ratio, 0.91 [95% CI, 0.54-1.55]; P = .74; difference, –1.8% [95% CI, –10.7% to 7.2%]). No statistically significant differences were noted in any of the 24 prespecified secondary outcomes. Conclusions and Relevance Among patients with malignant pleural effusion, thoracoscopic talc poudrage, compared with talc slurry delivered via chest tube, resulted in no significant difference in the rate of pleurodesis failure at 90 days. However, the study may have been underpowered to detect small but potentially important differences. Trial Registration ISRCTN Identifier: ISRCTN47845793</p

The effects of simulated obstructive apnea and hypopnea on arrhythmic potential in healthy subjects

Preliminary evidence supports an association between OSA and cardiac dysrhythmias. Negative intrathoracic pressure, as occurring during OSA, may provoke cardiac dysrhythmias. Thus, we aimed to study the acute effects of simulated apnea and hypopnea on arrhythmic potential and measures of cardiac repolarization [QT(C) and T (peak) to T (end) intervals ([Formula: see text])] in humans. In 41 healthy volunteers, ECG was continuously recorded prior, during and after simulated obstructive hypopnea (inspiration through a threshold load), simulated apnea (Mueller maneuver), end-expiratory central apnea and normal breathing in randomized order. The number of subjects with premature beats was significantly higher during inspiration through a threshold load (n = 7), and the Mueller maneuver (n = 7) compared to normal breathing (n = 0) (p = 0.008 for all comparisons), but not during end-expiratory central apnea (n = 3, p = 0.125). Inspiration through a threshold load was associated with a non-significant mean (SD) increase of the QT(C) interval [+5.4 (22.4) ms, 95 %CI -1.7 to +12.4 ms, p = 0.168] and a significant increase of the [Formula: see text] interval [+3.7 (8.9) ms, 95 %CI +0.9 to +6.6 ms, p = 0.010]. The Mueller maneuver induced a significant increase of the QT(C) interval [+8.3 (23.4) ms, 95 %CI 0.9 to +15.6 ms, p = 0.035] and the [Formula: see text] interval (+4.2 (8.2) ms, 95 %CI +1.6 to +6.8 ms, p = 0.002). There were no significant changes of the QT(C) and [Formula: see text] intervals during central end-expiratory apnea. These data indicate that simulated obstructive apnea and hypopnea are associated with an increase of premature beats and prolongation of QT(C) and [Formula: see text] intervals. Therefore, negative intrathoracic pressure changes may be a contributory mechanism for the association between OSA and cardiac dysrhythmias