The Role of Weight Management in the Treatment of Adult Obstructive Sleep Apnea. An Official American Thoracic Society Clinical Practice Guideline.

BACKGROUND: Overweight/obesity is a common, reversible risk factor for obstructive sleep apnea severity (OSA). The purpose of this guideline is to provide evidence-based recommendations for the management of overweight/obesity in patients with OSA. METHODS: The Grading of Recommendations, Assessment, Development and Evaluation approach was used to evaluate the literature. Clinical recommendations were formulated by a panel of pulmonary, sleep medicine, weight management, and behavioral science specialists. RESULTS: Behavioral, pharmacological, and surgical treatments promote weight loss and can reduce OSA severity, reverse common comorbidities, and improve quality of life, although published studies have methodological limitations. After considering the quality of evidence, feasibility, and acceptability of these interventions, the panel made a strong recommendation that patients with OSA who are overweight or obese be treated with comprehensive lifestyle intervention consisting of 1) a reduced-calorie diet, 2) exercise or increased physical activity, and 3) behavioral guidance. Conditional recommendations were made regarding reduced-calorie diet and exercise/increased physical activity as separate management tools. Pharmacological therapy and bariatric surgery are appropriate for selected patients who require further assistance with weight loss. CONCLUSIONS: Weight-loss interventions, especially comprehensive lifestyle interventions, are associated with improvements in OSA severity, cardiometabolic comorbidities, and quality of life. The American Thoracic Society recommends that clinicians regularly assess weight and incorporate weight management strategies that are tailored to individual patient preferences into the routine treatment of adult patients with OSA who are overweight or obese.

Ambulatory Surgery Has Minimal Impact on Sleep Parameters: A Prospective Observational Trial.

STUDY OBJECTIVES: The presence of obstructive sleep apnea (OSA) in ambulatory surgical patients causes significant perioperative concern; however, few data exist to guide clinicians' management decisions. The objective of this study was to measure changes in perioperative sleep parameters among an ambulatory surgery population. METHODS: This study is a prospective, observational study of ambulatory patients undergoing orthopedic surgery on an extremity. Study subjects completed three unattended home sleep apnea tests: baseline before surgery, the first night after surgery (N1), and third night after surgery (N3). Anesthesia and surgical teams were blinded to study participation and patients received routine perioperative care. RESULTS: Two hundred three subjects were enrolled and 166 completed the baseline home sleep test. Sixty-six (40.0%) had OSA at baseline, 35 patients received a new diagnosis, and 31 patients had a previous diagnosis of OSA. Of those with a previous diagnosis, 20 (64.5%) were compliant with continuous positive airway pressure therapy. Respiratory event index and SpO2 nadir did not significantly change postoperatively from baseline. Cumulative percentage of time oxygen saturation < 90% significantly increased N1 as compared to baseline for all patients except for those with moderate to severe OSA. CONCLUSIONS: Ambulatory surgery had minimal effect on sleep parameters and there was no increase in adverse events among patients with either treated or untreated OSA. CLINICAL TRIAL REGISTRATION: Registry: ClinicalTrials.gov; Title: Evaluation of Sleep Disordered Breathing Following Ambulatory Surgery; Identifier: NCT01851798; URL: https://clinicaltrials.gov/ct2/show/study/NCT01851798.

Impact of diagnosing and treating obstructive sleep apnea on healthcare utilization.

PURPOSE: Obstructive sleep apnea (OSA) contributes to an increased risk for multiple co-morbidities and decreased quality of life. As a result, OSA patients may have higher usage of healthcare resources which can be mitigated with effective treatment. This study evaluates changes in healthcare utilization (HCU) following the initiation of therapy for OSA. METHODS: We conducted a retrospective study of newly diagnosed OSA patients. To assess total HCU, we incorporated the sum total of outpatient clinic encounters, laboratory tests, and medication prescriptions into a composite HCU score. Healthcare utilization for twelve months prior to positive airway pressure (PAP) was compared with twelve months after initiation of therapy. Reductions in HCU were correlated with PAP adherence. RESULTS: 650 consecutive patients were included. Mean age, gender, BMI, AHI, and ESS were 47.2 ± 8.8 years, 77.2% (men), 30.7 ± 4.9 kg/m2, 37.1 ± 30.3, and 13.1 ± 5.1, respectively. Prior to PAP, mean outpatient visits, laboratory studies, medication prescriptions, and HCU composite score were 11.6 ± 10.4, 13.7 ± 11.0, 4.7 ± 3.2, and 29.7 ± 18.6, respectively. Following initiation of treatment, a 32.8% reduction in non-sleep outpatient visits was identified (p = 0.01) and a 16.4% decrease in laboratory studies (p = 0.02) was observed. There was a 19.9% reduction (p = 0.002) in HCU composite score. Those who were adherent with PAP had a 25.7% reduction in HCU composite score versus a 4.9% increase in those who discontinued PAP therapy (p < 0.001). CONCLUSIONS: Diagnosing OSA and initiating PAP therapy resulted in a significant decrease in healthcare resource utilization. This reduction was greatest among those with higher baseline healthcare usage and those most adherent with therapy.

Postoperative CPAP use impacts long-term weight loss following bariatric surgery.

INTRODUCTION: Obstructive sleep apnea (OSA) is common among bariatric surgery candidates. After surgical weight loss, OSA frequently persists and untreated OSA can lead to weight gain. Long-term continuous positive airway pressure (CPAP) adherence is unclear and poor adherence may worsen weight loss outcomes. We sought to determine the impact of CPAP use on long-term weight-loss outcomes in a cohort of bariatric patients. METHODS: Long-term observational study of bariatric surgery patients with OSA. Patients were evaluated with polysomnography preoperatively and one-year postoperatively. The cohort was again evaluated a mean of 7.2 years later to determine the relationship between long-term CPAP use and subsequent regain of weight. RESULTS: Twenty-four consecutive patients (aged 48.5 ± 9.4 years at time of surgery; 73% female) were included in the initial assessment, and long-term outcome data were available on 22 subjects. Persistent OSA was documented in 21 of 22 subjects (95%) one year postoperatively. Final evaluation occurred 7.2 ± 2.3 years following surgery. Weight (213.3 ± 39.1 to 235.3 ± 47.1 lb, p = 0.10) and BMI (32.5 ± 5.4 to 37.3 ± 8.2 kg/m(2), p = 0.03) increased in most (n = 19, 86.4%) from postoperative to final evaluation. CPAP use declined from 83.3% (preoperatively) to 38.1% (one year) and to 23.8% (final evaluation). BMI increased among those not using CPAP at long-term follow-up compared to those with continued CPAP use (6.8% v -1.8%, p = 0.05). CONCLUSIONS: In our cohort of bariatric patients with OSA, long-term adherence to CPAP therapy was poor, and non-adherence was associated with weight gain. Ongoing follow-up of OSA in this population may help to preserve initial achievements after surgical weight loss.

Bronchial arterial embolisation for massive haemoptysis in cavitary sarcoidosis.

A 48-year-old non-smoking man with a 6-year history of pulmonary cavitary sarcoidosis presented with acute onset of haemoptysis of approximately 600 ml. Prior episodes of haemoptysis had resolved only after serial upper lobe wedge resections bilaterally and steroids. A chest CT identified bilateral upper lobe cavitary lesions with extravasation of contrast from a large right upper lobe cavity. The patient underwent urgent bronchial angiography and subsequent bronchial artery embolisation of a left bronchial artery and three right bronchial arteries. He was started on methotrexate and steroids for refractory sarcoidosis. Two years after embolisation, the patient remained haemoptysis-free with his sarcoid well controlled on methotrexate monotherapy.

Sleep disturbances among soldiers with combat-related traumatic brain injury.

BACKGROUND: Sleep complaints are common among patients with traumatic brain injury. Evaluation of this population is confounded by polypharmacy and comorbid disease, with few studies addressing combat-related injuries. The aim of this study was to assess the prevalence of sleep disorders among soldiers who sustained combat-related traumatic brain injury. METHODS: The study design was a retrospective review of soldiers returning from combat with mild to moderate traumatic brain injury. All underwent comprehensive sleep evaluations. We determined the prevalence of sleep complaints and disorders in this population and assessed demographics, mechanism of injury, medication use, comorbid psychiatric disease, and polysomnographic findings to identify variables that correlated with the development of specific sleep disorders. RESULTS: Of 116 consecutive patients, 96.6% were men (mean age, 31.1 ± 9.8 years; mean BMI, 27.8 ± 4.1 kg/m²), and 29.5% and 70.5% sustained blunt and blast injuries, respectively. Nearly all (97.4%) reported sleep complaints. Hypersomnia and sleep fragmentation were reported in 85.2% and 54.3%, respectively. Obstructive sleep apnea syndrome (OSAS) was found in 34.5%, and 55.2% had insomnia. Patients with blast injuries developed more anxiety (50.6% vs 20.0%, P = .002) and insomnia (63% vs 40%, P = .02), whereas patients with blunt trauma had significantly more OSAS (54.3% vs 25.9%, P = .003). In multivariate analysis, blunt trauma was a significant predictor of OSAS (OR, 3.09; 95% CI, 1.02-9.38; P = .047). CONCLUSIONS: Sleep disruption is common following traumatic brain injury, and the majority of patients develop a chronic sleep disorder. It appears that sleep disturbances may be influenced by the mechanism of injury in those with combat-related traumatic brain injury, with blunt injury potentially predicting the development of OSAS.

Does home sleep testing impair continuous positive airway pressure adherence in patients with obstructive sleep apnea?

BACKGROUND: The increasing recognition of obstructive sleep apnea (OSA) and demand for polysomnography has created a need for home sleep testing (HST) using unattended diagnostic and titration studies. Although these studies increase access to care and reduce cost, the limited interaction with sleep laboratories may negatively affect positive airway pressure (PAP) adherence. We sought to determine the difference in PAP use between HST and traditional in-laboratory studies. METHODS: This observational cohort study included 210 patients with OSA classified into three equal groups. Following preestablished guidelines, group 1 underwent unattended, type III home diagnostic and unattended home auto-adjustable PAP (APAP) titrations; group 2 underwent in-laboratory, type I diagnostic and continuous PAP titration studies; group 3 underwent type I diagnostic and APAP titration studies. Group 1 was primarily managed and educated in a primary care clinic, whereas groups 2 and 3 received extensive education in an academic sleep medicine center. Objective measures of PAP use during the first 4 to 6 weeks of therapy were compared between groups. RESULTS: Type of study and location of care did not affect PAP adherence. PAP was used for 70%, 73%, and 72% of nights in groups 1, 2, and 3, respectively (P = .94). Mean hours of nightly use (4.4 ± 2.0 h, 4.7 ± 1.5 h, and 4.6 ± 1.5 h; P = .98) was also similar. Regular use was observed in 54%, 51%, and 50% of subjects (P = .84). Discontinuation rates were similar between groups. CONCLUSIONS: PAP usage did not differ between those undergoing HST vs in-laboratory studies. HST offers a more accessible and cost-effective alternative without compromising therapeutic adherence.

Obstructive sleep apnea presenting as pseudopheochromocytoma.

A 39-year-old man with a history of poorly controlled hypertension presented with a 2-year history of fatigue, daytime somnolence, and intermittent episodes of diaphoresis and palpitations. Episodes were self-limiting, lasting approximately 5-10 minutes and occurred several times per month, most notably at night. Laboratory evaluation was significant for elevated 24-h urinary catecholamine levels, suggestive of pheochromocytoma. However, thorough imaging failed to identify a catecholamine-secreting tumor. Subsequent polysomnography revealed severe obstructive sleep apnea, with an apnea-hypopnea index of 112 events/h. After one month of continuous positive airway pressure therapy, the patient experienced resolution of his presenting symptoms, improved blood pressure control and normalization of his urinary catecholamine levels. This case highlights sleep disordered breathing as a potentially reversible cause of pseudopheochromocytoma.

Effects of surgical weight loss on measures of obstructive sleep apnea: a meta-analysis.

OBJECTIVE: Limited evidence suggests bariatric surgery can result in high cure rates for obstructive sleep apnea (OSA) in the morbidly obese. We performed a systematic review and meta-analysis to identify the effects of surgical weight loss on the apnea-hypopnea index. METHODS: Relevant studies were identified by computerized searches of MEDLINE and EMBASE (from inception to March 17, 2008), and review of bibliographies of selected articles. Included studies reported results of polysomnographies performed before and at least 3 months after bariatric surgery. Data abstracted from each article included patient characteristics, sample size who underwent both preoperative and postoperative polysomnograms, types of bariatric surgery performed, results of preoperative and postoperative measures of OSA and body mass index, publication year, country of origin, trial perspective (prospective vs retrospective), and study quality. RESULTS: Twelve studies representing 342 patients were identified. The pooled mean body mass index was reduced by 17.9 kg/m(2) (95% confidence interval [CI], 16.5-19.3) from 55.3 kg/m(2) (95% CI, 53.5-57.1) to 37.7 kg/m(2) (95% CI, 36.6-38.9). The random-effects pooled baseline apnea hypopnea index of 54.7 events/hour (95% CI, 49.0-60.3) was reduced by 38.2 events/hour (95% CI, 31.9-44.4) to a final value of 15.8 events/hour (95% CI, 12.6-19.0). CONCLUSION: Bariatric surgery significantly reduces the apnea hypopnea index. However, the mean apnea hypopnea index after surgical weight loss was consistent with moderately severe OSA. Our data suggest that patients undergoing bariatric surgery should not expect a cure of OSA after surgical weight loss. These patients will likely need continued treatment for OSA to minimize its complications.

Persistence of obstructive sleep apnea after surgical weight loss.

STUDY OBJECTIVES: Weight loss may reduce the severity of obstructive sleep apnea (OSA), but persistence of OSA following surgical weight loss has not been defined. We sought to clarify the impact of bariatric surgery on OSA. We hypothesized that, despite substantial weight loss and reductions in the apnea-hypopnea index (AHI), many will have persistent disease. METHODS: Consecutive patients referred for preoperative sleep evaluation underwent polysomnography before and 1 year following bariatric surgery. We compared the effects of weight loss on body mass, OSA, and continuous positive airway pressure requirements. We defined OSA severity using the AHI (normal < 5 events per hour, mild 5 to 14 events per hour, moderate 15 to 29 events per hour, and severe 30 or more events per hour). We identified predictors of OSA severity following weight loss and assessed compliance with therapy. RESULTS: Twenty-four patients (aged 47.9 +/- 9.3 years; 75% women) were enrolled. At baseline, all subjects had OSA, the majority of which was severe. Weight loss reduced body mass index from 51.0 +/- 10.4 kg/m2 to 32.1 +/- 5.5 kg/m2 (p < 0.001) and the AHI from 47.9 +/- 33.8 to 24.5 +/- 18.1 events per hour (p < 0.001). At follow-up, only 1 patient (4%) experienced resolution of OSA. The majority (71%) had moderate or severe disease. The most important predictor of the follow-up AHI was the baseline AHI (R2 = 0.603). All patients with residual OSA required continuous positive airway pressure to ablate apneic events, but the required pressures decreased from 11.5 +/- 3.6 cm H2O to 8.4 +/- 2.1 cm H20 (p = 0.001). Only 6 patients were compliant with continuous positive airway pressure therapy at the follow-up visit. CONCLUSIONS: Surgical weight loss reduces the AHI, but many patients have residual OSA one year after bariatric surgery.

Impact of perioperative cardiac assessment guidelines on management of orthopedic surgery patients.

PURPOSE: The study assessed whether the American College of Cardiology/American Heart Association (ACC/AHA) preoperative cardiac assessment guidelines impact patient management and predict major cardiac events in patients undergoing orthopedic surgery. SUBJECTS AND METHODS: We conducted a retrospective review of 338 consecutive orthopedic preoperative evaluations performed by internal medicine consultants. Major cardiac events were defined as myocardial infarction, congestive heart failure, and sudden cardiac death. RESULTS: Major cardiac events occurred in 5.7% of patients. Patients with minor or absent ACC/AHA clinical risk predictors were less likely to have major cardiac events (P = .007). More than half (51%) of patients meeting ACC/AHA indications for noninvasive cardiac tests did not receive them. However, most (69%) major cardiac events occurred in patients not meeting criteria for cardiac testing. Abnormal noninvasive cardiac testing results did not alter medication recommendations and only resulted in coronary revascularization in 0.6% of patients. Only 3% of patients with abnormal noninvasive cardiac testing results had major cardiac events. Patients with abnormal cardiac test results were more likely to have recommendations for perioperative beta-blockade (P <.01). Patients aged more than 70 years (odds ratio 5.0; 95% confidence interval, 1.32-19.28) and patients undergoing hip surgery (odds ratio 7.5, 95% confidence interval, 1.02-54.55) were more likely to have major cardiac events. Major cardiac events occurred in 12% of urgent and 4% of elective procedures (P = .009). CONCLUSIONS: The ACC/AHA guidelines accurately predict cardiac risk in orthopedic surgery. Abnormal noninvasive cardiac test results rarely affected preoperative recommendations, but improved compliance with beta-blocker therapy. Advanced age, urgent procedures, and hip surgery were associated with increased risk of major cardiac events.

Discordance between general and pulmonary pathologists in the diagnosis of interstitial lung disease.

BACKGROUND: Interstitial lung diseases (ILDs) often present diagnostic challenges to both the clinician and pathologist. Surgical lung biopsy (SLB) is often pursued in the evaluation of ILD and the clinician uses the histopathologic conclusions to guide management. However, the agreement between general and pulmonary pathologists in histopathologic diagnosis of ILD has not been established. OBJECTIVE: To determine the agreement between general and pulmonary pathologists in the histopathologic interpretation of ILDs and whether disagreements result in changes in clinical management. METHODS: We retrospectively reviewed all patients who underwent SLB for ILD at our institution, between 1996 and 2002. We compared the interpretations of general pathologists to those of pulmonary pathologists to evaluate the degree of inter-rater agreement. We assumed the specialist pathologist represented the "gold standard." We further determined if changes in the histopathologic diagnosis altered clinical management. RESULTS: Of 83 subjects who underwent SLB, 44 (mean age 58.5 +/- 14.2, 47.7% male) were examined by both general and specialty pathologists. There was poor agreement between the two sets of reviewers. The histopathologic interpretation by the specialist pathologist differed from the generalist in 52.3% of cases (kappa 0.21, P < 0.0001). This high rate of discordance led to frequent (60.0%) changes in clinical management. As a screening test for usual interstitial pneumonia, the observations of the general pathologist had moderate sensitivity and specificity (76.5% and 66.7%, respectively). CONCLUSIONS: General and pulmonary pathologists often differ in their interpretation of the histopathology in ILD. This significant discordance may have important clinical implications for patient care.

Outcomes and safety of surgical lung biopsy for interstitial lung disease.

STUDY OBJECTIVES: To determine the safety of surgical lung biopsy (SLB) in patients with interstitial lung disease (ILD), and specifically in those with idiopathic pulmonary fibrosis (IPF). DESIGN: Retrospective cohort. SETTING: Tertiary care university-affiliated military medical center. PATIENTS: Individuals undergoing SLB for suspected ILD. MEASUREMENTS AND RESULTS: We examined outcomes for subjects with a clinical diagnosis of ILD who had been designated to undergo SLB. Mortality (assessed at 30 and 90 days) following SLB represented the primary end point. Morbidity resulting from complications from SLB served as a secondary end point. The cohort included 83 patients (mean [+/- SD] age, 57.3 +/- 14.2 years; men, 57.8%). IPF was eventually diagnosed in slightly more than half of the subjects. Overall, 30-day and 90-day mortality rates were low (4.8% and 6.0%, respectively). Subjects with IPF did well with SLB (30-day mortality rate, 7.1%) and did not face a higher risk of either death or complications relative to individuals with non-IPF forms of ILD. The only predictors of perioperative mortality were either the need for mechanical ventilation (MV) at the time of SLB or being immunosuppressed prior to undergoing SLB. Excluding persons who met either criterion yielded an overall 90-day post-SLB mortality rate of 1.5% in persons with IPF. Approximately 40% of patients in whom IPF was eventually diagnosed were initially thought to have another form of ILD. CONCLUSIONS: Persons with IPF tolerate SLB well. Requiring MV or being immunosuppressed is associated with an increased risk for death following SLB. Safety concerns should not preclude referral for SLB in patients who are clinically suspected of having IPF.

Intralobular bronchopulmonary sequestrations associated with bronchogenic cysts.

We present three cases of intralobar bronchopulmonary sequestrations with associated congenital bronchogenic cysts. As congenital abnormalities tend to be found together, these cases question the notion that intralobar sequestrations only occur secondary to chronic inflammation or infection, and suggest they can be congenital lesions.

Depreotide scanning in sarcoidosis: a pilot study.

STUDY OBJECTIVES: To determine whether sarcoidosis results in uptake on (99m)Tc-labeled depreotide (DP) scintigraphy and to generate preliminary data to guide the development of future trials exploring this imaging modality in sarcoidosis patients. DESIGN: Prospective cohort trial among a convenience sample of patients with sarcoidosis. SETTING: Tertiary care medical center pulmonary clinic. PATIENTS: Subjects in whom sarcoidosis has been diagnosed based on a biopsy revealing nonnecrotizing granulomas. INTERVENTIONS: Two hours after IV administration of (99m)Tc-DP, all patients underwent whole-body anterior and posterior planar imaging, followed by thoracic single-photon emission CT scanning. Images were interpreted by two nuclear medicine physicians who were blinded to the patient's clinical status. MEASUREMENTS AND RESULTS: The study cohort included 22 subjects (mean [+/- SD] age, 41.3 +/- 9.3 years; 40% female). Approximately half of the cohort had stage I disease determined by chest radiographs (CXRs). The results of (99m)Tc-DP scintigraphy were positive for sarcoidosis in 18 individuals (81.8%; 95% confidence interval, 59.7 to 94.8%). Of the four persons lacking (99m)Tc-DP uptake, all had normalized their CXRs since the time of presentation. In the entire sample, the intraclass correlation between radiographic stage determined by CXR vs that determined by (99m)Tc-DP scintigraphy was robust (kappa = 0.79; p = 0.0005). Among patients with positive (99m)Tc-DP scan findings, the correlation was stronger (kappa = 0.94; p < 0.0001). Flow rates and lung volumes were lower in patients with parenchymal activity on (99m)Tc-DP scintigraphy (mean FEV(1), 68.6 +/- 13.9% predicted vs 84.5 +/- 10.7% predicted, respectively [p = 0.012]; mean FVC, 74.0 +/- 16.0% predicted vs 88.4 +/- 12.7% predicted [p = 0.041]). (99m)Tc-DP scintigraphy correctly identified all sites of known nonpulmonary visceral involvement with sarcoidosis. CONCLUSIONS: The results of (99m)Tc-DP imaging are often positive in sarcoidosis patients, and correlate with disease stage determined by CXR and pulmonary function. (99m)Tc-DP scintigraphy does not preclude the need for biopsy if this is indicated to confirm the diagnosis of sarcoidosis or to exclude the possibility of malignancy. (99m)Tc-DP scintigraphy merits further study in the evaluation and management of sarcoidosis.

Clinical features of non-Hodgkins lymphoma presenting with acute liver failure: a report of five cases and review of published experience.

Hematological malignancies frequently affect the liver, but typically do not result in hepatic dysfunction and rarely present with advanced hepatic involvement. We report five patients who presented with advanced hepatic involvement and were found to have a high-grade lymphoma infiltrating the liver. Despite early diagnosis and initiation of therapy, all five patients deteriorated rapidly and died shortly after the onset of liver failure. Several similar cases have been reported. They share common clinical features, including hepatomegaly, lactic acidosis, and death shortly after the onset of symptoms. Non-Hodgkins lymphoma is a common malignancy, which is increasing in incidence. Non-Hodgkins lymphoma is not commonly entertained as an etiology of advanced liver failure and is likely underrecognized. In cases of acute advanced liver failure without an apparent etiology, especially if associated with hepatomegaly and lactic acidosis, lymphoma should be considered because of its poor prognosis and potential for treatment if recognized early. Liver biopsy is an invaluable tool that provides an early diagnosis while excluding other potential etiologies for acute advanced liver failure.