Profile of Acute Asthma Exacerbation in Drug Users.

The characteristics of patients who use heroin, cocaine, or both and present with acute asthma exacerbations have not been well studied. In this retrospective study, we aimed to study the demographic characteristics of this patient population, the characteristics of their asthma attack, and the risk factors for the need for invasive mechanical ventilation in this patient population. We reviewed the charts of patients discharged from an inner-city hospital with a diagnosis of acute asthma exacerbation. Individuals who used either heroin or cocaine or both within 24 hours of presenting to the emergency department were identified as a cohort of drug users. The rest were classified as non-drug users. Both groups were compared, and a univariate analysis was performed. To assess the predictive value of drug use for the need for intubation in the presence of confounding factors, logistic regression analysis was performed to identify whether using cocaine or heroin or both was an individual predictor for the need for invasive ventilation. Data from 218 patients were analyzed. Drug users (n = 85) were younger (mean age in years 43.9 vs. 50.5, P < 0.01), predominantly male (63.5% vs. 33.8%, P < 0.01), and more likely to be cigarette smokers (90.6% vs. 57.6%, P < 0.01). A medical history of intubation and admissions to the intensive care unit (ICU) was more common among drug users (56.5% vs. 29.3%, P < 0.01 and 54.1% vs. 38.3%, P < 0.03, respectively). Drug use was associated with increased need for invasive mechanical ventilation (35% vs. 23.3%, P = 0.05). Non-drug users were more likely to be using inhaled corticosteroids (48.9% vs. 32.9%, P = 0.03) and had longitudinal care established with a primary care provider (50.6% vs. 68.9%, P < 0.01). After adjusting for a history of mechanical ventilation, history of ICU admission, use of systemic corticosteroids, smoking, and acute physiological assessment and chronic health evaluation 2 score, drug use remained predictive for the need for mechanical ventilation (P = 0.026). Acute asthma exacerbations triggered by cocaine and heroin should be treated aggressively because they represent a cohort with poor follow-up and undertreated asthma as outpatients and are associated with increased need for invasive mechanical ventilation and ICU admission during acute exacerbation.

Effect of Positive Airway Pressure Therapy on Body Mass Index in Obese Patients With Obstructive Sleep Apnea Syndrome: A Prospective Study.

Because obesity is a common cause of obstructive sleep apnea syndrome (OSAS), weight loss can be an effective treatment. OSAS also may cause weight gain in some patients. Effective treatment of sleep apnea may facilitate weight loss in obese patients. We hypothesize that positive airway pressure (PAP) therapy is associated with weight loss in obese patients with OSAS. This was a single-center observational prospective cohort study. Forty-five patients were diagnosed with OSAS after polysomnographic analysis in sleep laboratory and underwent continuous positive airway pressure titration. Patients were followed for 3 months in terms of change in body mass index (BMI) and compliance with PAP therapy. Of the 45 patients recruited, 3 patients were eliminated because of miss recruitment. Nine patients had incomplete data, and the rest (n = 33) were included for analysis. The mean age was 54.9 ± 16.9 years (mean ± SD), 93.9% were male, and 90.9% were whites. Mean apnea-hypopnea index was 36.3 ± 28.17 events per hour. Mean BMI before treatment was 34.7 ± 3.9 kg/m. Fifteen patients (45.5%) were compliant with therapy of OSAS with PAP. There was no difference in age, gender, neck circumference, BMI, and apnea-hypopnea index of patients compliant to therapy when compared with those who were not. There was a significant decrease in BMI in patients compliant with PAP therapy compared with noncompliant patients (-1.2 ± 0.7 vs. 0.3 ± 0.9 kg/m, P ≤ 0.001). PAP therapy may cause significant loss of weight within 3 months in obese patients with OSAS. Further study is needed to elucidate the physiological basis of this change.

Association of Extubation Failure and Functional Outcomes in Patients with Acute Neurologic Illness.

BACKGROUND: An association between extubation failure and neurologic and functional outcomes in patients with primary neurologic illness has not been investigated rigorously. We plan to conduct a retrospective chart review to study this association. METHODS: A total of 949 unique patients intubated and ventilated for at least 48 h in Neuro ICU (NICU) were obtained. Extubation failure was defined as need for reintubation within 48 h of initial extubation. Independent and dependent association between extubation failure and clinical parameters was assessed. RESULTS: The patients had a median age [interquartile range (IQR)] of 58.5 (23.0) years. 60.5% were male and 81.9% were Caucasian. Extubation failure occurred in 108 (12.8%) patients. There was no difference in age, APACHE 3 score, FOUR score, or GCS score of patients at ICU admission between those who experienced extubation failure and those who did not. Extubation failure was associated with longer NICU and hospital LOS [median (IQR); 13.7 (11.3) vs. 9.1(8.2) days, P < 0.01 and 24.5 (20.0) vs. 16.8 (16.7) days, P < 0.01]. Patients with extubation failure had worse functional outcomes at 6 months as measured by the modified Rankin score [MRS; median (IQR), 5.0 (2.0) vs. 4.0 (3.0), P < 0.01]. After adjusting for confounders, extubation failure was associated with longer hospital and ICU LOS and worse functional outcomes. CONCLUSIONS: In patients with acute neurological illness, extubation failure is associated with longer ICU and hospital stays but does not impact hospital mortality. Patients with extubation failure may experience a worsening of their functional status over time.

Retrospective derivation and validation of a search algorithm to identify extubation failure in the intensive care unit.

BACKGROUND: Development and validation of automated electronic medical record (EMR) search strategies is important in identifying extubation failure in the intensive care unit (ICU). We developed and validated an automated search algorithm (strategy) for extubation failure in critically ill patients. METHODS: The EMR search algorithm was created through sequential steps with keywords applied to an institutional EMR database. The search strategy was derived retrospectively through secondary analysis of a 100-patient subset from the 978 patient cohort admitted to a neurological ICU from January 1, 2002, through December 31, 2011(derivation subset). It was, then, validated against an additional 100-patient subset (validation subset). Sensitivity, specificity, negative and positive predictive values of the automated search algorithm were compared with a manual medical record review (the reference standard) for data extraction of extubation failure. RESULTS: In the derivation subset of 100 random patients, the initial automated electronic search strategy achieved a sensitivity of 85% (95% CI, 56%-97%) and a specificity of 95% (95% CI, 87%-98%). With refinements in the search algorithm, the final sensitivity was 93% (95% CI, 64%-99%) and specificity increased to 100% (95% CI, 95%-100%) in this subset. In validation of the algorithm through a separate 100 random patient subset, the reported sensitivity and specificity were 94% (95% CI, 69%-99%) and 98% (95% CI, 92%-99%) respectively. CONCLUSIONS: Use of electronic search algorithms allows for correct extraction of extubation failure in the ICU, with high degrees of sensitivity and specificity. Such search algorithms are a reliable alternative to manual chart review for identification of extubation failure.

Permanent standard time is the optimal choice for health and safety: an American Academy of Sleep Medicine position statement.

The period of the year from spring to fall, when clocks in most parts of the United States are set one hour ahead of standard time, is called daylight saving time, and its beginning and ending dates and times are set by federal law. The human biological clock is regulated by the timing of light and darkness, which then dictates sleep and wake rhythms. In daily life, the timing of exposure to light is generally linked to the social clock. When the solar clock is misaligned with the social clock, desynchronization occurs between the internal circadian rhythm and the social clock. The yearly change between standard time and daylight saving time introduces this misalignment, which has been associated with risks to physical and mental health and safety, as well as risks to public health. In 2020, the American Academy of Sleep Medicine (AASM) published a position statement advocating for the elimination of seasonal time changes, suggesting that evidence best supports the adoption of year-round standard time. This updated statement cites new evidence and support for permanent standard time. It is the position of the AASM that the United States should eliminate seasonal time changes in favor of permanent standard time, which aligns best with human circadian biology. Evidence supports the distinct benefits of standard time for health and safety, while also underscoring the potential harms that result from seasonal time changes to and from daylight saving time. CITATION: Rishi MA, Cheng JY, Strang AR, et al. Permanent standard time is the optimal choice for health and safety: an American Academy of Sleep Medicine position statement. J Clin Sleep Med. 2024;20(1):121-125.

Rapid eye movement related obstructive sleep apnea: Where do we stand?

Rapid eye movement (REM) related obstructive sleep apnea (OSA) is defined by the presence of episodes of apnea or hypopnea predominantly or exclusively during REM sleep. Epidemiology of this disorder shows a complex interaction with age, sex, and body mass index. The prevalence is variable and depends on the criteria used to define this disorder. Moreover, the clinical significance of this entity remains poorly defined. However, episodes of apnea or hypopnea encountered during REM sleep are longer and are associated with a more profound drop in oxygen saturation than non-REM sleep. Likewise, this disorder may be independently associated with hypertension and poor glycemic control. More importantly, positive airway pressure therapy as currently prescribed may not treat the majority of apnea episodes during REM sleep. The treatment is further complicated by the different definitions used for the diagnosis of this disorder and the lack of consensus if patients with this diagnosis should be treated if their overall apnea-hypopnea index does not meet the threshold for the clinical diagnosis of OSA. The definition and treatment used for the diagnosis and management of REM-related OSA needs to be standardized. Moreover, a consensus needs to be developed as to whether patients with this disorder should be treated if their overall apnea-hypopnea index does not meet the threshold for the clinical diagnosis of OSA. Further investigation may help answer if this disorder is independently associated with neurocognitive and cardiometabolic adverse outcomes and help guide the therapeutic approach.

What is the role of sleep in physician burnout?

None: The occurrence of physician burnout is widespread among clinicians and academic faculty, who report indicators such as low quality of life and poor work-life balance. Chronic insufficient sleep, whether due to extended work hours, circadian misalignment, or unrecognized sleep disorders, is a critically important risk factor for burnout that is overlooked and under-studied, and interventions to promote healthy sleep may reduce burnout susceptibility among attending physicians. While strategies to reduce burnout among resident and attending physicians have been under-evaluated, evidence suggests a need to address burnout at both individual and organizational levels. Solutions have been offered that are applicable to many stakeholders, including employers; payers; licensing and certification boards; state and federal regulatory agencies; and physicians and researchers. As more studies are undertaken to evaluate how these approaches impact burnout, two questions need to be addressed: (1) What is the role of sleep in the crisis of burnout, specifically among attendings, who are particularly under-studied? (2) Is restoration of healthy sleep the fundamental mechanism by which burnout interventions work? It is essential for key stakeholders to consider the role of sleep, sleepiness, and sleep disorders in order to optimize any efforts to mitigate the present crisis in physician burnout, particularly among attending physicians, an understudied group.

Daylight saving time: an American Academy of Sleep Medicine position statement.

None: The last several years have seen intense debate about the issue of transitioning between standard and daylight saving time. In the United States, the annual advance to daylight saving time in spring, and fall back to standard time in autumn, is required by law (although some exceptions are allowed under the statute). An abundance of accumulated evidence indicates that the acute transition from standard time to daylight saving time incurs significant public health and safety risks, including increased risk of adverse cardiovascular events, mood disorders, and motor vehicle crashes. Although chronic effects of remaining in daylight saving time year-round have not been well studied, daylight saving time is less aligned with human circadian biology-which, due to the impacts of the delayed natural light/dark cycle on human activity, could result in circadian misalignment, which has been associated in some studies with increased cardiovascular disease risk, metabolic syndrome and other health risks. It is, therefore, the position of the American Academy of Sleep Medicine that these seasonal time changes should be abolished in favor of a fixed, national, year-round standard time.

Sleep, fatigue and burnout among physicians: an American Academy of Sleep Medicine position statement.

None: Physician burnout is a serious and growing threat to the medical profession and may undermine efforts to maintain a sufficient physician workforce to care for the growing and aging patient population in the United States. Burnout involves a host of complex underlying associations and potential for risk. While prevalence is unknown, recent estimates of physician burnout are quite high, approaching 50% or more, with midcareer physicians at highest risk. Sleep deprivation due to shift-work schedules, high workload, long hours, sleep interruptions, and insufficient recovery sleep have been implicated in the genesis and perpetuation of burnout. Maladaptive attitudes regarding sleep and endurance also may increase the risk for sleep deprivation among attending physicians. While duty-hour restrictions have been instituted to protect sleep opportunity among trainees, virtually no such effort has been made for attending physicians who have completed their training or practicing physicians in nonacademic settings. It is the position of the American Academy of Sleep Medicine that a critical need exists to evaluate the roles of sleep disruption, sleep deprivation, and circadian misalignment in physician well-being and burnout. Such evaluation may pave the way for the development of effective countermeasures that promote healthy sleep, with the goal of reducing burnout and its negative impacts such as a shrinking physician workforce, poor physician health and functional outcomes, lower quality of care, and compromised patient safety.

Atypical antipsychotic medications are independently associated with severe obstructive sleep apnea.

BACKGROUND: Atypical antipsychotic (AA) medications are widely prescribed for their Food and Drug Administration-approved uses (acute mania, bipolar mania, psychotic agitation, bipolar maintenance, etc) and off-label indications. Although AA medications are associated with substantial weight gain, their tranquilizing effects may independently contribute to risk of obstructive sleep apnea (OSA) perhaps, by a reduction in activity of hypoglossal or recurrent activity of laryngeal nerve on the upper motor airway musculature. METHODS: We hypothesized that AA medications are associated with more severe OSA independent of weight and neck circumference. Medical intake data and polysomnographic studies of patients referred to community hospital sleep disorders center were analyzed retrospectively. RESULTS: Mean age of patients was 49.1 years, 55.1% were male, and mean body mass index (BMI) was 33.8 kg/m. Sixty-eight patients (8.1%) were taking AA at the time of polysomnography. There were no differences in age, sex, neck circumference and BMI of AA versus non-AA patients. The mean (SE) apnea-hypopnea index values were 29.2 (3.5)/h in AA patients and 21.3 (0.8)/h in non-AA patients (P = 0.03). Thirty-four percent of AA patients had severe OSA (apnea-hypopnea index > 30/h) compared with 23% of non-AA patients (P = 0.04). When adjusted for BMI, sex, and use of benzodiazepines and sleeping aids, the odds ratios of severe OSA in AA patients were 1.9 times in non-AA patients (95% confidence interval, 1.1-3.3). CONCLUSIONS: Atypical antipsychotic medication use may increase the risk of more severe OSA independent of weight and neck circumference.