Correlation between positive airway pressure and medication adherence: the healthy user effect.

STUDY OBJECTIVES: Despite the efficacy of positive airway pressure (PAP) for the treatment of obstructive sleep apnea, adherence remains challenging and negatively affects assessments of effectiveness. It is unclear whether low adherence is due to intolerance of PAP or whether this reflects overall adherence with medical therapy. We sought to correlate PAP use with medication adherence to determine whether poor adherence with PAP was specific to this treatment or represented global compliance with medical therapy. METHODS: A total of 600 consecutive patients with obstructive sleep apnea were treated with PAP. Objective measures of PAP use were correlated with medication adherence. We included all chronically used medications, defined as medications used daily for at least 90 days prior to PAP initiation. Medication use was verified using an electronic health record. PAP adherence ("regular use") was defined as PAP use for ≥ 4 hours/night on ≥ 70% of nights. Medication adherence was defined as > 70% of pills taken as prescribed. RESULTS: Complete records were available for 566 patients; 361 (63.8%) used chronic medications. The cohort was primarily men (90.3%, age 44.6 ± 10.2 years) with moderate obstructive sleep apnea (apnea-hypopnea index, 18.1 ± 13.9 events/h). In patients on chronic medications, PAP was used 55.8% of nights and 37.7% were regular users. Patients who were adherent with medications used PAP more hours/night (5.4 vs 4.6, P < .001) and were more likely to have regular PAP use compared with those nonadherent with medications (P = .04). CONCLUSIONS: Adherence with PAP correlated with adherence to chronic medications. Low PAP adherence may reflect an individual's global adherence to medical care. This association may lead to better identification of patients who benefit from targeted therapy to improve overall health care adherence. CITATION: Lettieri MJ, Warren WA, Walter RJ, Lettieri CJ. Correlation between positive airway pressure and medication adherence: the healthy user effect. J Clin Sleep Med. 2024;20(7):1087-1092.

Posttraumatic Stress Disorder Is Associated With a Decrease in Anaerobic Threshold, Oxygen Pulse, and Maximal Oxygen Uptake.

BACKGROUND: Posttraumatic stress disorder (PTSD) has been linked to respiratory symptoms and functional limitations, but the mechanisms leading to this association are poorly defined. RESEARCH QUESTION: What is the relationship between PTSD, lung function, and the cardiopulmonary response to exercise in combat veterans presenting with chronic respiratory symptoms? STUDY DESIGN AND METHODS: This study prospectively enrolled military service members with respiratory symptoms following deployment to southwest Asia. All participants underwent a comprehensive evaluation that included pulmonary function testing and cardiopulmonary exercise testing. Pulmonary function test variables and cardiopulmonary response to exercise were compared in subjects with and without PTSD by using multivariable linear regression to adjust for confounders. RESULTS: A total of 303 participants were included (PTSD, n = 70; non-PTSD, n = 233). Those with PTSD had a greater frequency of current respiratory symptoms. There were no differences in measures for airway disease or lung volumes, but patients with PTSD had a reduction in diffusing capacity that was eliminated following adjustment for differences in hemoglobin levels. Participants with PTSD had a lower anaerobic threshold (23.9 vs 26.4 cc/kg per minute; P = .004), peak oxygen pulse (19.7 vs 18.5 cc/beat; P = .03), and peak oxygen uptake (34.5 vs 38.8 cc/kg per minute; P < .001). No significant difference was observed in gas exchange, respiratory reserve, or effort at peak exercise between participants with and without PTSD. INTERPRETATION: A diagnosis of PTSD was associated with a reduced anaerobic threshold, oxygen pulse, and peak oxygen uptake. This objective reduction in cardiopulmonary work is independent of baseline lung function, was not associated with abnormalities in gas exchange or respiratory reserve, and may be related to deconditioning.

A 21-Year-Old Man With a Cough.

CASE PRESENTATION: A 21-year-old male African American college student from Southern California, with no significant medical history, was visiting family in southwestern Texas when he presented to the hospital with 1 week history of cough, shortness of breath, lower back pain, and a 10-pound weight loss.

A 24-Year-Old Woman With Precipitous Respiratory Failure After Lung Transplantation.

CASE PRESENTATION: A 24-year-old woman with ΔF508/Y1092X cystic fibrosis (CF) complicated by severe obstructive lung disease (FEV1 of 30% predicted) was admitted for IV antibiotics for planned sinus surgery resulting from severe chronic sinusitis causing frequent exacerbations and declining lung function. She had persistent airway infection with multidrug-resistant Pseudomonas aeruginosa, methicillin-resistant Staphylococcus aureus, and growth of a fungus presumed to be an airway colonizer, identified as Stephanoascus ciferrii 1 year before presentation. Two days after surgery, she developed acute respiratory failure requiring mechanical ventilation. On day 4 of mechanical ventilation, venovenous-extracorporeal membrane oxygenation (VV-ECMO) was initiated for refractory respiratory failure. The following day, she was listed for bilateral lung transplant and was transplanted 4 days later. Following transplantation, she was decannulated from ECMO; however, over the next 12 hours, oxygenation deteriorated requiring reinstitution of VV-ECMO for presumed severe primary graft dysfunction. Despite treatment with broad spectrum antimicrobial coverage with piperacillin/tazobactam, ciprofloxacin, linezolid, micafungin, voriconazole, and ganciclovir, she failed to improve and developed complex bilateral pleural effusions.

Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration for Mediastinal Staging in a Community Medical Center.

RATIONALE: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and positron emission tomography (PET)-computed tomography (CT) are valuable tools for lung cancer staging. Data from tertiary referral centers suggest that these modalities are superior to mediastinoscopy in mediastinal staging. OBJECTIVES: To validate EBUS-TBNA for lung cancer staging in a community center with operators with various levels of experience. METHODS: At an 800-bed community hospital, we reviewed all cases where EBUS-TBNA and PET-CT were performed for mediastinal staging by one of seven private practice pulmonologists. Cases were reviewed with lymph node dissection by mediastinoscopy after negative EBUS-TBNA. MEASUREMENTS AND MAIN RESULTS: Of the 333 cases that were reviewed, 44 underwent mediastinoscopy after negative EBUS-TBNA. Four patients were positive for malignancy at stations 4R and 7 lymph nodes. In none of these cases did EBUS-TBNA reveal lymphoid tissue confirming the sample location. PET-CT showed mediastinal lymph nodes with increased avidity in two of the false-negative cases. EBUS-TBNA plus PET-CT had a sensitivity, specificity, and negative predictive value of 98.86, 100, and 94.87%, respectively, compared with mediastinoscopy for detecting metastasis. CONCLUSIONS: EBUS-TBNA is accurate in detecting mediastinal metastasis of lung cancer in the community setting. PET-CT without uptake in lymph nodes reduces the likelihood of malignancy but cannot rule out mediastinal involvement.

Ten Years of Chronic Cough in a 64-Year-Old Man With Multiple Pulmonary Nodules.

A 64-year-old male former smoker with a history of prostate cancer presented to our pulmonary clinic, complaining of nonproductive cough for 10 years. Prior evaluation included treatment for upper airway cough syndrome and gastroesophageal reflux, stopping angiotensin-converting enzyme inhibitor, and initiation of inhaled ß-agonists. Esophageal pH monitoring indicated silent reflux, and proton pump inhibitor therapy was started. He continued to cough and complain of dyspnea. Physical examination produced unremarkable results, with no evidence of lymphadenopathy. Pulmonary function tests showed a pseudo-restrictive pattern with air trapping, hyperreactivity, and incomplete bronchodilator responsiveness: FEV1, 2.48 L (69% of predicted); FVC, 3.57 L (75% of predicted); FEV1/FVC, 92%; total lung capacity, 7.00 L (100% of predicted); and residual volume, 3.05 L (136% of predicted). Laboratory studies, including a complete metabolic panel, prostate-specific antigen test, and complete blood count, yielded normal results.

Pulmonary nodule tracking using chest computed tomography in a histoplasmosis endemic area.

OBJECTIVE: In areas with endemic histoplasmosis, incidental pulmonary nodules are common. Rate of malignancy and applicability of current tracking guidelines in these regions remain unclear. METHODS: A total of 148 cases of incidental pulmonary nodules tracked with chest computed tomography were reviewed for radiologic characteristics, diagnosis, number, and size. RESULTS: Of the nodules, 87.8% were benign and 12.2% malignant; 30% of nodules >20mm were malignant. Number of nodules (P=.14) and granulomatous disease (P=.71) were not related to malignant diagnosis. CONCLUSION: Malignancy was lower than expected in nodules >20mm. Appropriate tracking guidelines for incidentally discovered nodules in histoplasmosis endemic regions must be determined.