Impact of sleep disturbances on outcomes in intensive care units.

BACKGROUND: Sleep deprivation is common in intensive care units (ICUs) and may alter respiratory performance. Few studies have assessed the role of sleep disturbances on outcomes in critically ill patients. OBJECTIVES: We hypothesized that sleep disturbances may be associated with poor outcomes in ICUs. METHODS: Post-hoc analysis pooling three observational studies assessing sleep by complete polysomnography in 131 conscious and non-sedated patients included at different times of their ICU stay. Sleep was assessed early in a group of patients admitted for acute respiratory failure while breathing spontaneously (n = 34), or under mechanical ventilation in patients with weaning difficulties (n = 45), or immediately after extubation (n = 52). Patients admitted for acute respiratory failure who required intubation, those under mechanical ventilation who had prolonged weaning, and those who required reintubation after extubation were considered as having poor clinical outcomes. Durations of deep sleep, rapid eye movement (REM) sleep, and atypical sleep were compared according to the timing of polysomnography and the clinical outcomes. RESULTS: Whereas deep sleep remained preserved in patients admitted for acute respiratory failure, it was markedly reduced under mechanical ventilation and after extubation (p < 0.01). Atypical sleep was significantly more frequent in patients under mechanical ventilation than in those breathing spontaneously (p < 0.01). REM sleep was uncommon at any time of their ICU stay. Patients with complete disappearance of REM sleep (50% of patients) were more likely to have poor clinical outcomes than those with persistent REM sleep (24% vs. 9%, p = 0.03). CONCLUSION: Complete disappearance of REM sleep was significantly associated with poor clinical outcomes in critically ill patients.

Impact of Sleep Deprivation on Respiratory Motor Output and Endurance. A Physiological Study.

Rationale: Sleep deprivation can alter endurance of skeletal muscles, but its impact on respiratory command is unknown.Objectives: We aimed to assess the effect of sleep deprivation on respiratory motor output and inspiratory endurance.Methods: Inspiratory endurance was investigated twice in random order, following a normal sleep night and a sleepless night. Healthy participants were asked to breathe as long as possible until task failure against a moderate inspiratory threshold constraint. Transdiaphragmatic pressure and diaphragm electrical activity were measured throughout the trial to assess pressure output of the diaphragm and overall respiratory motor output. Cortical contribution to respiratory motor output was assessed by measurement of preinspiratory motor potential amplitude and by cervical magnetic simulation.Measurements and Main Results: Twenty healthy male participants were studied. Time to task failure was significantly shorter after sleep deprivation than after normal sleep: (30 min [interquartile range [IQR], 17-41] vs. 60 min [IQR, 45-60], P = 0.002). At the beginning of the trial, preinspiratory motor potential amplitude was significantly lower in the sleep-deprivation condition (4.5 µV [IQR, 2.5-6.4] vs. 7.3 µV [IQR, 4.3-10.4], P = 0.02) and correlated significantly with the duration of the endurance trial. In the sleep-deprivation condition, preinspiratory motor potential amplitude, electrical activity of the diaphragm, pressure output of the diaphragm, and Vt decreased and the respiratory rate increased significantly from the beginning to the end of the trial. Such decreases did not occur in the normal-sleep condition.Conclusions: One night of sleep deprivation reduces respiratory motor output by altering its cortical component with subsequent reduction of inspiratory endurance by half. These results suggest that altered sleep triggers severe brain dysfunctions that could precipitate respiratory failure.

Impact of sleep alterations on weaning duration in mechanically ventilated patients: a prospective study.

Sleep is markedly altered in intensive care unit (ICU) patients and may alter respiratory performance. Our objective was to assess the impact of sleep alterations on weaning duration.We conducted a prospective physiological study at a French teaching hospital. ICU patients intubated for at least 24 h and difficult to wean were included. Complete polysomnography (PSG) was performed after the first spontaneous breathing trial failure. Presence of atypical sleep, duration of sleep stages, particularly rapid eye movement (REM) sleep, and electroencephalogram (EEG) reactivity at eyes opening were assessed by a neurologist.20 out of 45 patients studied (44%) had atypical sleep that could not be classified according to the standard criteria. Duration of weaning between PSG and extubation was significantly longer in patients with atypical sleep (median (interquartile range) 5 (2-8) versus 2 (1-2) days; p=0.001) and in those with no REM sleep compared with the others. Using multivariate logistic regression analysis, atypical sleep remained independently associated with prolonged weaning (>48 h after PSG). Altered EEG reactivity at eyes opening was a good predictor of atypical sleep.Our results suggest for the first time that brain dysfunction may have an influence on the ability to breathe spontaneously.

Physiologic Effects of Reconnection to the Ventilator for 1 Hour Following a Successful Spontaneous Breathing Trial.

BACKGROUND: Reconnection to the ventilator for 1 h following a successful spontaneous breathing trial (SBT) may reduce reintubation rates compared with direct extubation. However, the physiologic mechanisms leading to this effect are unclear. RESEARCH QUESTION: Does reconnection to the ventilator for 1 h reverse alveolar derecruitment induced by SBT, and is alveolar derecruitment more pronounced with a T-piece than with pressure-support ventilation (PSV)? STUDY DESIGN AND METHODS: This is an ancillary study of a randomized clinical trial comparing SBT performed with a T-piece or with PSV. Alveolar recruitment was assessed by using measurement of end-expiratory lung volume (EELV). RESULTS: Of the 25 patients analyzed following successful SBT, 11 underwent SBT with a T-piece and 14 with PSV. At the end of the SBT, EELV decreased by -30% (95% CI, -37 to -23) compared with baseline prior to the SBT. This reduction was greater with a T-piece than with PSV: -43% (95% CI, -51 to -35) vs -20% (95% CI, -26 to -13); P < .001. Following reconnection to the ventilator for 1 h, EELV accounted for 96% (95% CI, 92 to 101) of baseline EELV and did not significantly differ from prior to the SBT (P = .104). Following 10 min of reconnection to the ventilator, EELV wasted at the end of the SBT was completely recovered using PSV (P = .574), whereas it remained lower than prior to the SBT using a T-piece (P = .010). INTERPRETATION: Significant alveolar derecruitment was observed at the end of an SBT and was markedly more pronounced with a T-piece than with PSV. Reconnection to the ventilator for 1 h allowed complete recovery of alveolar derecruitment. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov; No.: NCT04227639; URL: www. CLINICALTRIALS: gov.

A real-time automated sleep scoring algorithm to detect refreshing sleep in conscious ventilated critically ill patients.

OBJECTIVES: Due to the noisy environment, a very large number of patients admitted to intensive care units (ICUs) suffer from sleep severe disruption. These sleep alterations have been associated with a prolonged need for assisted ventilation or even with death. Sleep scoring in the critically ill is very challenging and requires sleep experts, limiting relevant studies to a few experienced teams. In this context, an automated scoring system would be of interest for researchers. In addition, real-time scoring could be used by nurses to protect patients' sleep. We devised a sleep scoring algorithm working in real time and compared this automated scoring against visual scoring. METHODS: We analyzed retrospectively 45 polysomnographies previously recorded in non-sedated and conscious ICU patients during their weaning phase. For each patient, one EEG channel was processed, providing automated sleep scoring. We compared total sleep time obtained with visual scoring versus automated scoring. The proportion of sleep episodes correctly identified was calculated. RESULTS: Automated total sleep time and visual sleep time were correlated; the automatic system overestimated total sleep time. The median [25th-75th] percentage of sleep episodes lasting more than 10 min detected by algorithm was 100% [73.2 - 100.0]. Median sensitivity was 97.9% [92.5 - 99.9]. CONCLUSION: An automated sleep scoring system can identify nearly all long sleep episodes. Since these episodes are restorative, this real-time automated system opens the way for EEG-guided sleep protection strategies. Nurses could cluster their non-urgent care procedures, and reduce ambient noise so as to minimize patients' sleep disruptions.

Correlation Between Sleep Continuity and Patient-Reported Sleep Quality in Conscious Critically Ill Patients at High Risk of Reintubation: A Pilot Study.

OBJECTIVES: It is well-established that sleep quality of ICU patients is poor, with sleep being highly fragmented by multiple awakenings. These sleep disruptions are associated with poor outcomes such as prolonged weaning duration from mechanical ventilation. Polysomnography can measure sleep continuity, a parameter associated positively with outcomes in patients treated with noninvasive ventilation, but polysomnography is not routinely available in all ICUs, and simple means to assess sleep quality are needed. The Richards-Campbell sleep questionnaire (RCSQ) assesses sleep quality in ICU patients but is difficult to administrate in patients who are not fully awake, and a simpler sleep numeric rating scale (sleep-NRS) has been proposed as an alternative. We here investigated the relationships between sleep continuity and patients-reported sleep quality. DESIGN: Single-center retrospective study. SETTING: Medical ICU of Poitiers University Hospital. PATIENTS: Seventy-two patients were extubated from mechanical ventilation and at high risk of reintubation. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We analyzed 52 previously recorded polysomnographies in nonsedated and conscious ICU patients. Sleep was recorded the night after extubation. Sleep continuity was measured using an automated scoring algorithm from one electroencephalogram (EEG) channel of the polysomnography. Patient-reported sleep quality was assessed using RCSQ and sleep-NRS. Sleep continuity could be calculated on 45 polysomnographies (age: 68 [58-77], median [25th-75th]) RCSQ (62 [48-72]) and sleep-NRS (6.0 [5.0-7.0]) were obtained in 21 patients and 34 patients, respectively. Our results show a significant correlation between sleep continuity and sleep-NRS (p = 0.0037; ρ = 0.4844; n = 34) but not with RCSQ score (p = 0.6732; ρ = 0.1005; n = 20). CONCLUSION: Sleep continuity correlates with patient-reported sleep quality assessed using sleep-NRS and may capture the refreshing part of sleep. Sleep-NRS can be easily administered in ICU patients. Sleep continuity and sleep-NRS are simple tools that may prove useful to evaluate sleep quality in ICU patients.

Sleep Assessment in Critically Ill Patients With Acute Hypoxemic Respiratory Failure.

BACKGROUND: Sleep deprivation alters respiratory muscle performance and may precipitate respiratory failure. This study aimed to assess sleep in subjects admitted to ICU for acute hypoxemic respiratory failure and its role in the risk of intubation. METHODS: This was a prospective observational single-center cohort study including subjects admitted to ICU for de novo acute hypoxemic respiratory failure defined as breathing frequency ≥ 25 breaths/min or clinical signs of respiratory distress and PaO2 /FIO2 < 300 mm Hg while receiving high-flow nasal oxygen. Subjects with altered consciousness, central nervous or psychiatric disorders, continuous sedation or neuroleptic medication, or were uncooperative were excluded. Sleep was assessed by complete polysomnography (PSG) the night following ICU admission. The main outcome was to assess sleep among subjects with acute hypoxemic respiratory failure and to compare sleep between subjects who eventually required intubation to those who did not. RESULTS: Over a 24-month inclusion period, 34 subjects had complete PSG, among whom 5 (15%) required intubation in the ICU. Total sleep time was 4.2 h in median (interquartile range 2.9-6.8); deep-sleep duration was 70 min (34-127), and rapid eye movement (REM) sleep duration was 9 min (0-28). Among them, 13 subjects (38%) had no REM sleep. Total sleep time and duration of deep and REM sleep stages did not differ between subjects who required intubation and those successfully treated with high-flow nasal oxygen. CONCLUSIONS: Whereas total sleep time remained relatively preserved in critically ill subjects with acute hypoxemic respiratory failure, REM sleep time was uncommon or completely absent in a large number of subjects. Sleep did not differ between subjects who required intubation and those who did not. However, given a trend toward an increased risk of intubation in subjects with a complete absence of REM sleep, further studies are needed to better explore the impact of REM sleep on the risk of intubation.

ß Agonist Delivery by High-Flow Nasal Cannula During COPD Exacerbation.

BACKGROUND: Whereas high-flow nasal cannula (HFNC) oxygen therapy is increasingly used in patients with exacerbation of COPD, the effectiveness of ß 2 agonist nebulization through HFNC has been poorly assessed. We hypothesized that salbutamol vibrating-mesh nebulization through HFNC improves pulmonary function tests in subjects with COPD. METHODS: We conducted a physiological crossover study including subjects admitted to the ICU for severe exacerbation of COPD. After subject improvement allowing a 3-h washout period without bronchodilator, pulmonary function tests were performed while breathing through HFNC alone and after salbutamol vibrating-mesh nebulization through HFNC. The primary end point consisted in the changes in FEV1 before and after salbutamol nebulization. Secondary end points included the changes in FVC, peak expiratory flow (PEF), airway resistance, and clinical parameters. RESULTS: Among the 15 subjects included, mean (SD) FEV1 significantly increased after salbutamol nebulization from 931 mL (383) to 1,019 (432), mean difference +87 mL (95% CI 30-145) (P = .006). Similarly, FVC and PEF significantly increased, +174 mL (95% CI 66-282) (P = .004) and +0.3 L/min (95% CI 0-0.6) (P = .037), respectively. Airway resistances and breathing frequency did not significantly differ, whereas heart rate significantly increased after nebulization. CONCLUSIONS: In subjects with severe exacerbation of COPD, salbutamol vibrating-mesh nebulization through HFNC induced a significant bronchodilator effect with volume and flow improvement.

Sleep deprivation reduces vagal tone during an inspiratory endurance task in humans.

STUDY OBJECTIVES: Sleep deprivation alters inspiratory endurance by reducing inspiratory motor output. Vagal tone is involved in exercise endurance. This study aimed to investigate the effect of sleep deprivation on vagal tone adaptation in healthy subjects performing an inspiratory effort. METHODS: Vagal tone was assessed using Heart Rate Variability normalized units of frequency domain component HF (high frequency) before, at the start, and the end of an inspiratory loading trial performed until exhaustion by 16 volunteers after one night of sleep deprivation and one night of normal sleep, where sleep deprivation reduced the inspiratory endurance by half compared to the normal sleep condition (30 min vs 60 min). RESULTS: At rest, heart rate was similar in sleep deprivation and normal sleep conditions. In normal sleep condition, heart rate increased during inspiratory loading task; this increase was greater in sleep deprivation condition. In normal sleep condition, vagal tone increased at the beginning of the trial. This vagal tone increase was absent in sleep deprivation condition. CONCLUSIONS: Sleep deprivation abolished vagal tone response to inspiratory load, possibly contributing to a higher heart rate during the trial and to a reduced inspiratory endurance. CLINICAL TRIAL REGISTRATION: NCT02725190.

Role of sleep on respiratory failure after extubation in the ICU.

BACKGROUND: Sleep had never been assessed immediately after extubation in patients still in the ICU. However, sleep deprivation may alter respiratory function and may promote respiratory failure. We hypothesized that sleep alterations after extubation could be associated with an increased risk of post-extubation respiratory failure and reintubation. We conducted a prospective observational cohort study performed at the medical ICU of the university hospital of Poitiers in France. Patients at high-risk of extubation failure (> 65 years, with any underlying cardiac or lung disease, or intubated > 7 days) were included. Patients intubated less than 24 h, with central nervous or psychiatric disorders, continuous sedation, neuroleptic medication, or uncooperative were excluded. Sleep was assessed by complete polysomnography just following extubation including the night. The main objective was to compare sleep between patients who developed post-extubation respiratory failure or required reintubation and the others. RESULTS: Over a 3-year period, 52 patients had complete polysomnography among whom 12 (23%) developed post-extubation respiratory failure and 8 (15%) required reintubation. Among them, 10 (19%) had atypical sleep, 15 (29%) had no deep sleep, and 33 (63%) had no rapid eye movement (REM) sleep. Total sleep time was 3.2 h in median [interquartile range, 2.0-4.4] in patients who developed post-extubation respiratory failure vs. 2.0 [1.1-3.8] in those who were successfully extubated (p = 0.34). Total sleep time, and durations of deep and REM sleep stages did not differ between patients who required reintubation and the others. Reintubation rates were 21% (7/33) in patients with no REM sleep and 5% (1/19) in patients with REM sleep (difference, - 16% [95% CI - 33% to 6%]; p = 0.23). CONCLUSIONS: Sleep assessment by polysomnography after extubation showed a dramatically low total, deep and REM sleep time. Sleep did not differ between patients who were successfully extubated and those who developed post-extubation respiratory failure or required reintubation.