Evaluating the impact and costs of conversional or revisional metabolic bariatric surgery on obstructive sleep apnea: Insights from a French nationwide cohort.

BACKGROUND: This study assesses the effectiveness of 5 main conversional or revisional metabolic bariatric surgery sequences after sleeve gastrectomy, adjustable gastric banding and gastric bypass on reimbursement and cost of continuous positive airway pressure therapy, the first line treatment for obstructive sleep apnea, in France. METHODS: This nationwide observational population-based cohort study analyzed data from the French National Health Insurance database. It included all patients who had undergone primary metabolic bariatric surgery in France between January 1, 2012, and December 31, 2014, and followed until December 31, 2020. The study assessed continuous positive airway pressure therapy reimbursement discontinuation and costs of reimbursed continuous positive airway pressure therapy across 5 different conversional or revisional metabolic bariatric surgery sequences. RESULTS: During follow-up, 6,396 patients underwent the following sequences: sleeve gastrectomy-gastric bypass (n = 2,400), adjustable gastric banding-sleeve gastrectomy (n = 2,277), adjustable gastric banding-gastric bypass (n = 1,173), sleeve gastrectomy-sleeve gastrectomy (n = 546), and gastric bypass-others (n =332), with a rate of obstructive sleep apnea of 15.2%, 12.4%, 15.5% 12.8%, and 9.9% in the year before conversional or revisional metabolic bariatric surgery. The rates of patients who had a discontinuation of continuous positive airway pressure were at 2 and 4 years: 41.1%, 41.9%, 46.4%, 29.3%, and 33.3%; 62.3%, 57.0%, 78.2%; 57.5%, and 44.4%, respectively. At 4 years, the mean annual costs (euros) of obstructive sleep apnea treatment per patient were significantly lower (P < .01) than the costs in the year before conversional or revisional metabolic bariatric surgery for each sequence: 526.9 ± 414.4 vs 257.4 ± 349.7; 368.0 ± 247.5 vs 230.9 ± 288.4; 433.7 ± 326.0 vs 116.8 ± 238.3; 540.7 ± 275.3 vs 248.0 ± 308.4 and 501.2 ± 254.0 vs 281.1 ± 287.0, respectively. CONCLUSIONS: Our study underscore the effectiveness of conversional or revisional metabolic bariatric surgery in significantly reducing the need and associated costs of continuous positive airway pressure therapy for patients with obstructive sleep apnea postprimary metabolic bariatric surgery over a 4-year period.

Association Between Sleep Apnea Treatment and Health Care Resource Use in Patients With Atrial Fibrillation.

BACKGROUND: Obstructive sleep apnea (OSA) contributes to the generation, recurrence, and perpetuation of atrial fibrillation, and it is associated with worse outcomes. Little is known about the economic impact of OSA therapy in atrial fibrillation. This retrospective cohort study assessed the impact of positive airway pressure (PAP) therapy adherence on health care resource use and costs in patients with OSA and atrial fibrillation. METHODS AND RESULTS: Insurance claims data for ≥1 year before sleep testing and 2 years after device setup were linked with objective PAP therapy use data. PAP adherence was defined from an extension of the US Medicare 90-day definition. Inverse probability of treatment weighting was used to create covariate-balanced PAP adherence groups to mitigate confounding. Of 5867 patients (32% women; mean age, 62.7 years), 41% were adherent, 38% were intermediate, and 21% were nonadherent. Mean±SD number of all-cause emergency department visits (0.61±1.21 versus 0.77±1.55 [P=0.023] versus 0.95±1.90 [P<0.001]), all-cause hospitalizations (0.19±0.69 versus 0.24±0.72 [P=0.002] versus 0.34±1.16 [P<0.001]), and cardiac-related hospitalizations (0.06±0.26 versus 0.09±0.41 [P=0.023] versus 0.10±0.44 [P=0.004]) were significantly lower in adherent versus intermediate and nonadherent patients, as were all-cause inpatient costs ($2200±$8054 versus $3274±$12 065 [P=0.002] versus $4483±$16 499 [P<0.001]). All-cause emergency department costs were significantly lower in adherent and intermediate versus nonadherent patients ($499±$1229 and $563±$1292 versus $691±$1652 [P<0.001 and P=0.002], respectively). CONCLUSIONS: These data suggest clinical and economic benefits of PAP therapy in patients with concomitant OSA and atrial fibrillation. This supports the value of diagnosing and managing OSA and highlights the need for strategies to enhance PAP adherence in this population.

Characterizing Decisional Conflict in Patients Presenting to Sleep Surgery Clinic and an Exploration of Resource Limitations.

OBJECTIVES: Numerous therapies exist for adult obstructive sleep apnea (OSA), creating potential for patient decisional conflict (DC) that impacts treatment adherence and post-treatment regret. We evaluated the prevalence of elevated DC in OSA patients presenting for positive airway pressure (PAP) alternative therapies and identified gaps in available resources about OSA therapies. STUDY DESIGN: Cross-sectional study. METHODS: A cross-sectional study was performed based on questionnaires completed by adult OSA patients presenting to an academic sleep surgery clinic from March to October 2020. Surveys examined sleep symptoms, sleep apnea treatment history, goals of therapy, and the SURE checklist, a validated 4-item DC screening scale. Additional qualitative data about OSA decision tool needs were queried with structured interviews in a smaller subset of patients. RESULTS: Among 100 respondents, 60 were open to multiple treatment options, whereas 22 were not interested in surgical treatment. Eighty-one respondents (81%) had elevated DC (SURE score < 4). High DC was not associated with CPAP history, OSA severity, or daytime sleepiness (Epworth Sleepiness Scale score ≥ 10). Elevated DC was related to uncertainty regarding optimal treatment choice in 54% of respondents (n = 54), and lack of knowledge regarding risks and benefits of each treatment option in 71% (n = 71). Common themes identified in 9 interviewed patients suggested helpful resources should ideally compare treatment modalities and educate on surgery details, efficacy, and recovery. CONCLUSIONS: The majority of OSA patients presenting to sleep surgery clinics have elevated decisional conflict influenced by limited knowledge about options and the risks and benefits of each therapy. There is a need for decision tools that can reduce decisional conflict and promote equitable knowledge about PAP alternative OSA treatments. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:2384-2390, 2021.

Protocol of a multicentre, prospective cohort study that evaluates cost-effectiveness of two perioperative care strategies for potential obstructive sleep apnoea in morbidly obese patients undergoing bariatric surgery.

INTRODUCTION: Despite the high prevalence of obstructive sleep apnoea (OSA) in obese patients undergoing bariatric surgery, OSA is undiagnosed in the majority of patients and thus untreated. While untreated OSA is associated with an increased risk of preoperative and postoperative complications, no evidence-based guidelines on perioperative care for these patients are available. The aim of the POPCORN study (Post-Operative Pulse oximetry without OSA sCreening vs perioperative continuous positive airway pressure (CPAP) treatment following OSA scReeNing by polygraphy (PG)) is to evaluate which perioperative strategy is the most cost-effective for obese patients undergoing bariatric surgery without a history of OSA. METHODS AND ANALYSIS: In this multicentre observational cohort study, data from 1380 patients who will undergo bariatric surgery will be collected. Patients will receive either postoperative care with pulse oximetry monitoring and supplemental oxygen during the first postoperative night, or care that includes preoperative PG and CPAP treatment in case of moderate or severe OSA. Local protocols for perioperative care in each participating hospital will determine into which cohort a patient is placed. The primary outcome is cost-effectiveness, which will be calculated by comparing all healthcare costs with the quality-adjusted life-years (QALYs, calculated using EQ-5D questionnaires). Secondary outcomes are mortality, complications within 30 days after surgery, readmissions, reoperations, length of stay, weight loss, generic quality of life (QOL), OSA-specific QOL, OSA symptoms and CPAP adherence. Patients will receive questionnaires before surgery and 1, 3, 6 and 12 months after surgery to report QALYs and other patient-reported outcomes. ETHICS AND DISSEMINATION: Approval from the Medical Research Ethics Committees United was granted in accordance with the Dutch law for Medical Research Involving Human Subjects Act (WMO) (reference number W17.050). Results will be submitted for publication in peer-reviewed journals and presented at (inter)national conferences. TRIAL REGISTRATION NUMBER: NTR6991.

Respiratory Support in COVID-19 Patients, with a Focus on Resource-Limited Settings.

The ongoing novel coronavirus disease (COVID-19) pandemic is threatening the global human population, including in countries with resource-limited health facilities. Severe bilateral pneumonia is the main feature of severe COVID-19, and adequate ventilatory support is crucial for patient survival. Although our knowledge of the disease is still rapidly increasing, this review summarizes current guidance on the best provision of ventilatory support, with a focus on resource-limited settings. Key messages include that supplemental oxygen is a first essential step for the treatment of severe COVID-19 patients with hypoxemia and should be a primary focus in resource-limited settings where capacity for invasive ventilation is limited. Oxygen delivery can be increased by using a non-rebreathing mask and prone positioning. The presence of only hypoxemia should in general not trigger intubation because hypoxemia is often remarkably well tolerated. Patients with fatigue and at risk for exhaustion, because of respiratory distress, will require invasive ventilation. In these patients, lung protective ventilation is essential. Severe pneumonia in COVID-19 differs in some important aspects from other causes of severe pneumonia or acute respiratory distress syndrome, and limiting the positive end-expiratory pressure level on the ventilator may be important. This ventilation strategy might reduce the currently very high case fatality rate of more than 50% in invasively ventilated COVID-19 patients.

Cost-effectiveness of obstructive sleep apnea screening for patients with diabetes or chronic kidney disease.

PURPOSE: Obstructive sleep apnea (OSA) is a common disorder with a high prevalence among patients with cardiovascular disease (CVD), diabetes, and chronic kidney disease (CKD). Routine evaluation of OSA for patients with CVD including hypertension has been performed according to the clinical guidelines for both OSA and CVD. However, most patients with diabetes and CKD who could benefit from treatment remain undiagnosed because routine screening of OSA is not recognized as part of standard practice. This study aims to evaluate the cost-effectiveness of OSA screening for patients with diabetes and CKD. METHODS: Cost-effectiveness analysis by a decision tree and Markov modeling from the societal perspective in Japan was carried out to provide evidence based on the economic evaluation of current clinical practice concerning diabetes and CKD. RESULTS: Incremental cost-effectiveness ratios of OSA screening compared with do-nothing were calculated as ¥3,516,976 to 4,514,813/quality-adjusted life year (QALY) (US$35,170 to 45,148/QALY) for diabetes patients and ¥3,666,946 to 4,006,866/QALY (US$36,669 to 40,069/QALY) for CKD patients. CONCLUSIONS: Taking the threshold to judge cost-effectiveness according to a suggested value of social willingness to pay for one QALY gain in Japan as ¥5 million/QALY (US$50,000QALY), OSA screening is cost-effective. Our results suggest that active case screening and treatment of OSA for untreated middle-aged male patients with diabetes or CKD could be justifiable as an efficient use of finite health-care resources in the world with high prevalence of these diseases.

Web-Based Access to Positive Airway Pressure Usage with or without an Initial Financial Incentive Improves Treatment Use in Patients with Obstructive Sleep Apnea.

STUDY OBJECTIVES: We tested whether providing adults with obstructive sleep apnea (OSA) with daily Web-based access to their positive airway pressure (PAP) usage over 3 mo with or without a financial incentive in the first week improves adherence and functional outcomes. SETTING: Academic- and community-based sleep centers. PARTICIPANTS: One hundred thirty-eight adults with newly diagnosed OSA starting PAP treatment. INTERVENTIONS: Participants were randomized to: usual care, usual care with access to PAP usage, or usual care with access to PAP usage and a financial incentive. PAP data were transmitted daily by wireless modem from the participants' PAP unit to a website where hours of usage were displayed. Participants in the financial incentive group could earn up to $30/day in the first week for objective PAP use ≥ 4 h/day. MEASUREMENTS AND RESULTS: Mean hours of daily PAP use in the two groups with access to PAP usage data did not differ from each other but was significantly greater than that in the usual care group in the first week and over 3 mo (P < 0.0001). Average daily use (mean ± standard deviation) during the first week of PAP intervention was 4.7 ± 3.3 h in the usual care group, and 5.9 ± 2.5 h and 6.3 ± 2.5 h in the Web access groups with and without financial incentive respectively. Adherence over the 3-mo intervention decreased at a relatively constant rate in all three groups. Functional Outcomes of Sleep Questionnaire change scores at 3 mo improved within each group (P < 0.0001) but change scores of the two groups with Web access to PAP data were not different than those in the control group (P > 0.124). CONCLUSIONS: Positive airway pressure adherence is significantly improved by giving patients Web access to information about their use of the treatment. Inclusion of a financial incentive in the first week had no additive effect in improving adherence.

The challenge of undiagnosed sleep apnea in low-risk populations: a decision analysis.

OBJECTIVES: Obstructive sleep apnea (OSA) may contribute to impaired performance among otherwise healthy active duty military personnel. We used decision analysis to evaluate three approaches to identifying and treating OSA in low-risk populations, which may differ from current standard practice for high-risk populations. METHODS: We developed a decision tree to compare two simple strategies for diagnosis and management of sleep apnea in a low-risk population. In one strategy, a simple screening inventory was followed by conventional laboratory polysomnography (split-night), whereas the alternative strategy involved performing home testing in all individuals. This allowed us to weigh the costs associated with large-scale diagnostic approaches against the costs of untreated OSA in a small fraction of the population. RESULTS: We found that the home testing approach was less expensive than the screen-then-test approach across a broad range of other important parameters, including the annual performance cost associated with untreated OSA, the prevalence of OSA, and the duration of active duty. CONCLUSIONS: Assuming even modest annual performance costs associated with untreated OSA, a population strategy involving large-scale home testing is less expensive than a screening inventory approach. These results may inform either targeted or large-scale investigation of undiagnosed OSA in low-risk populations such as active duty military.

Management of obstructive sleep apnea in the indigent population: a deviation of standard of care?

Comprehensive management of patients with obstructive sleep apnea (OSA) typically is managed best via a multidisciplinary approach, involving otolaryngologists, sleep psychologists/psychiatrists, pulmonologists, neurologists, oral surgeons, and sleep trained dentists. By utilizing these resources, one could fashion a treatment individualized to the patient, giving rise to the holistic phrase of "personalized medicine." Unfortunately, in situations and environments with limited resources, the treatment options in an otolaryngologist's armamentarium are restricted--typically to continuous positive airway pressure (CPAP) versus sleep surgery. However, a recent patient encounter highlighted here shows how a hospital's reimbursement policy effectively dictated a patient's medical management to sleep surgery. This occurred although the current gold standard for the initial treatment of OSA is CPAP. Changing the course of medical/surgical management by selectively restricting funding is a cause of concern, especially when it promotes patients to choose a treatment option that is not considered the current standard of care.

The economic impact of obstructive sleep apnea.

PURPOSE OF REVIEW: Obstructive sleep apnea (OSA) has a substantial economic impact on healthcare systems. We reviewed parameters affecting healthcare costs (race, low education, and socioeconomic status) on OSA comorbidity, and costs and the effect of OSA treatment on medical costs. RECENT FINDINGS: OSA is associated with increased cardiovascular disease (CVD) morbidity and substantially increased medical costs. Risk for OSA and resulting CVD are associated with obesity, tobacco smoking, black race, and low socioeconomic status; all these are associated with poor continuous positive airway pressure (CPAP) adherence. Healthcare costs are not normally distributed, that is, the costliest and the sickest upper third of patients consume 65-82% of all medical costs. Only a limited number of studies have explored the effect of CPAP on medical costs. SUMMARY: Costs of untreated OSA may double the medical expenses mainly because of CVD. Identifying the costliest, sickest upper third of OSA patients will reduce expenses to healthcare systems. Studies exploring the effect of CPAP on medical costs are essential. In addition, tailoring intervention programs to reduce barriers to adherence have the potential to improve CPAP treatment, specially in at-risk populations that are sicker and consume more healthcare costs.

The use of ambulatory strategies for the diagnosis and treatment of obstructive sleep apnea in adults.

Obstructive sleep apnea (OSA) is a highly prevalent disorder associated with complications such as arterial hypertension, coronary heart disease, cerebrovascular disease and traffic accidents. Patients with untreated OSA consume more financial and healthcare resources and have higher mortality than those treated properly. The resources allocated for OSA are insufficient in some countries for such a prevalent disorder. This has given rise to a significant public health problem and a search for alternative strategies based on the ambulatory management. In the diagnostic process, portable monitors have been evaluated. Continuous positive airway pressure is the most effective treatment in OSA, but other forms of treatments have also been used (weight loss, oral appliances, surgery and so on). Ambulatory monitoring of the therapeutic modalities has been evaluated to enhance the care process and reduce costs compared with the conventional approach, without sacrificing efficiency. This review aims to highlight the most important advances in this field, analyzing the results of the main works to date, in order to assess the current situation and future research needs.

[Trends in prevalence of continuous positive airway pressure treatment for adults from 2006 to 2010]. / Évolution de 2006 à 2010 du nombre d'adultes traités par pression positive continue.

INTRODUCTION: The aim of this study was to evaluate the evolution from 2006 to 2010 of the prevalence of continuous positive airway pressure treatment for the beneficiaries of two regional health care insurance funds (17 and 43). METHODS: One million forty-eight thousand four hundred and thirty beneficiary-years were analyzed from 2006 to 2010. The prevalence of continuous positive airway pressure treatment was tested with regard to the effect of the year of delivery. A logit regression was used to adjust for potentially confounding differences in age and gender, which were included as covariates. The prevalence of alternative treatments and of controls of reimbursement benefits implemented by the funds are evaluated too during the same period. RESULTS: Continuous positive airway pressure treatment annual prevalence was 6.34/1000. A significant annual increase of prevalence from 2006 to 2008 was followed by a slowing of the rate of growth starting from 2008. In the same time for fund 43, obesity surgery rose from 41.85/100,000 to 55.44/100,000 and mandibular osteotomy surgery rose from 0.97/100,000 to 4.78/100,000. For fund 17 mandibular advancement devices rose from 10.72/100,000 to 21,08/100,000. The two funds started a reinforced inspections of reimbursement benefits for continuous positive airway pressure treatment in 2008. CONCLUSIONS: The dynamics of continuous positive airway pressure treatment have to be considered in the context of policies introduced and trends in the application of alternative treatments in each fund.

Impact of positive airway pressure among obstructive sleep apnea patients.

OBJECTIVES: To evaluate the clinical and economic impact of positive airway pressure (PAP) among patients with obstructive sleep apnea (OSA). STUDY DESIGN: Retrospective claims-based analysis of OSA patients diagnosed with polysomnography (PSG) between January 1, 2005, and April 30, 2008. METHODS: Patients were required to have 2 or more claims for OSA diagnosis within 1 year after their first PSG test, and a minimum of 12 months' baseline and 24 months' follow-up continuous health plan enrollment. Patients with pulmonary disease or PAP use before the first PSG test were excluded. Outcomes included all-cause and sleep apnea-related hospitalization and healthcare costs. Multivariable analyses were performed to adjust for baseline characteristics. RESULTS: Of the 15,424 patients identified, 90.7% used PAP and 9.3% did not. The PAP group had lower all-cause (19.0% vs 24.2%, P <.001) and sleep apnea-related (8.0% vs 11.3%, P <.001) hospitalization rates than the non-PAP group during the follow-up period. After adjusting for baseline characteristics, patients in the PAP group were less likely to have an all-cause (odds ratio [OR] 0.70; 95% confidence interval [CI] 0.61-0.80]) or sleep apnea-related (OR 0.69; 95% CI 0.58-0.83) hospitalization than non-PAP patients. PAP users on average incurred 10% lower all-cause costs than non-PAP patients ($705 per member per month vs $786 per member per month, P <.001) in multivariable analysis. CONCLUSIONS: Among OSA patients in real-world practice, PAP users had significantly lower hospitalization risks and all-cause healthcare costs.

Financial incentive increases CPAP acceptance in patients from low socioeconomic background.

OBJECTIVE: We explored whether financial incentives have a role in patients' decisions to accept (purchase) a continuous positive airway pressure (CPAP) device in a healthcare system that requires cost sharing. DESIGN: Longitudinal interventional study. PATIENTS: The group receiving financial incentive (n = 137, 50.8±10.6 years, apnea/hypopnea index (AHI) 38.7±19.9 events/hr) and the control group (n = 121, 50.9±10.3 years, AHI 39.9±22) underwent attendant titration and a two-week adaptation to CPAP. Patients in the control group had a co-payment of $330-660; the financial incentive group paid a subsidized price of $55. RESULTS: CPAP acceptance was 43% greater (p = 0.02) in the financial incentive group. CPAP acceptance among the low socioeconomic strata (n = 113) (adjusting for age, gender, BMI, tobacco smoking) was enhanced by financial incentive (OR, 95% CI) (3.43, 1.09-10.85), age (1.1, 1.03-1.17), AHI (>30 vs. <30) (4.87, 1.56-15.2), and by family/friends who had positive experience with CPAP (4.29, 1.05-17.51). Among average/high-income patients (n = 145) CPAP acceptance was affected by AHI (>30 vs. <30) (3.16, 1.14-8.75), living with a partner (8.82, 1.03-75.8) but not by the financial incentive. At one-year follow-up CPAP adherence was similar in the financial incentive and control groups, 35% and 39%, respectively (p = 0.82). Adherence rate was sensitive to education (+yr) (1.28, 1.06-1.55) and AHI (>30 vs. <30) (5.25, 1.34-18.5). CONCLUSIONS: Minimizing cost sharing reduces a barrier for CPAP acceptance among low socioeconomic status patients. Thus, financial incentive should be applied as a policy to encourage CPAP treatment, especially among low socioeconomic strata patients.

[Non-invasive mechanical ventilation in COPD]. / Nichtinvasive Beatmung bei COPD.

Non-invasive mechanical ventilation is the preferred method for the treatment of acute respiratory failure in patients with chronic obstructive pulmonary disease (COPD). Primary contraindications and stopping criteria must be regarded to avoid delaying endotracheal intubation. The primary interface is usually a nasal-oral mask. Cautious sedation can facilitate non-invasive ventilation in some patients. Under certain circumstances non-invasive ventilation may enable successful extubation in COPD patients with prolonged weaning. COPD patients can also benefit from preventive non-invasive ventilation in order to avoid re-intubation after a planned extubation. Domiciliary nocturnal non-invasive ventilation is an option for some patients with COPD in chronic hypercapnic respiratory failure. This treatment should be established in a specialised unit.

Accuracy of the clinical parameters and oximetry to initiate CPAP in patients with suspected obstructive sleep apnea.

OBJECTIVE: The aim of this study was to assess the accuracy of oximetry and the clinical parameters for the prescription of continuous positive airway pressure (CPAP) in patients with suspected obstructive sleep apnea syndrome (OSAS). METHODS: All participants (135) performed oximetry (WristOx 3100™) and polysomnography (PSG) simultaneously in the sleep laboratory. The patients completed the Epworth sleepiness scale, the Berlin questionnaire, and a clinical history. Two blind independent observers decided to prescribe CPAP according to the results of the PSG (gold standard, observer A), oximetry (alternative method, observer B), and the clinical parameters. The accuracy of observer B on the indication of CPAP, using different cutoff points of the adjusted desaturation index (ADI3 and ADI4), was evaluated by the area under the receiver operating characteristics curve (AUC-ROC). The interobserver agreement for the indication of CPAP was assessed using kappa statistics. RESULTS: One hundred nineteen subjects were included (92 men; mean age, 53; median respiratory disturbance index, 22.6; median BMI, 27.5 kg/m(2)). Depending on the criteria used in oximetry, the sensitivity and specificity of observer B to initiate a CPAP trial ranged from 79.8% to 92.5% and of 92% to 96%, respectively. The best performance for the indication of CPAP was noted with the adjusted O(2) desaturation index ≥ 3% (AUC-ROC, 0.923). The inter-rater agreement for the prescription of CPAP was good (kappa, 0.60 to 0.79). CONCLUSION: This simulated study has shown that the use of oximetry plus clinical data has made it possible to indicate CPAP reliably in nearly 90% of the population with OSAS.

Impact of implementing 5 potentially better respiratory practices on neonatal outcomes and costs.

OBJECTIVE: We implemented 5 potentially better practices to limit mechanical ventilation (MV), supplemental oxygen, and bronchopulmonary dysplasia in newborn infants born before 33 weeks' gestation. METHODS: The methods used in this study included (1) exclusive use of bubble continuous positive airway pressure (bCPAP), (2) provision of bCPAP in the delivery room, (3) strict intubation criteria, (4) strict extubation criteria, and (5) prolonged CPAP to avoid supplemental oxygen. We excluded outborn infants and those with major anomalies and obstetric complications from analysis. RESULTS: Demographics were similar in 61 infants born before and 60 born after implementation. For infants born at 26 to 32(6/7) weeks' gestation, intubation (first 72 hours) decreased from 52% to 11% (P < .0001) and surfactant use decreased from 48% to 14% (P=.0001). In all infants, the mean ± SD fraction of inspired oxygen requirement (first 24 hours) decreased from 0.27 ± 0.08 to 0.24 ± 0.05 (P=.0005), days of oxygen decreased from 23.5 ± 44.5 to 9.3 ± 22.0 (P=.04), and days of MV decreased from 8.8 ± 27.8 to 2.2 ± 6.2 (P=.005). Hypotension decreased from 33% to 15% (P=.03). The percentage of infants with bronchopulmonary dysplasia was 17% before and 8% after (P=.27). Nurse staffing ratios remained unchanged. CONCLUSIONS: Implementation of these potentially better practices reduced the need for MV, surfactant, and supplemental oxygen as well as reduced hypotension among infants born before 33 weeks' gestation without adverse consequences. The costs for equipment and surfactant were lower.

Effective gas exchange in paralyzed juvenile rabbits using simple, inexpensive respiratory support devices.

We have developed two devices: a high-amplitude bubble continuous positive airway pressure (HAB-CPAP) and an inexpensive bubble intermittent mandatory ventilator (B-IMV) to test the hypotheses that simple, inexpensive devices can provide gas exchange similar to that of bubble CPAP (B-CPAP) and conventional mechanical ventilation (CMV). Twelve paralyzed juvenile rabbits were intubated, stabilized on CMV, and then switched to CPAP. On identical mean airway pressures (MAPs), animals were unable to maintain pulse oximeter oxygen saturation (SpO2) >80% on conventional B-CPAP, but all animals oxygenated well (97.3 ± 2.1%) on HAB-CPAP. In fact, arterial partial pressures of O2 (Pao2) were higher during HAB-CPAP than during CMV (p = 0.01). After repeated lung lavages, arterial partial pressures of CO2 (Paco2) were lower with B-IMV than with CMV (p < 0.0001), despite identical ventilator settings. In lavaged animals, when HAB-CPAP was compared with CMV at the same MAP and 100% O2, no differences were observed in Pao2, but Paco2 levels were higher with HAB-CPAP (70 ± 7 versus 50 ± 5 mm Hg; p < 0.05). Arterial blood pressures were not impaired by HAB-CPAP or B-IMV. The results confirm that simple inexpensive devices can provide respiratory support in the face of severe lung disease and could extend the use of respiratory support for preterm infants into severely resource-limited settings.

Low socioeconomic status is a risk factor for CPAP acceptance among adult OSAS patients requiring treatment.

STUDY OBJECTIVE: To evaluate whether socioeconomic status (SES) has a role in obstructive sleep apnea syndrome (OSAS) patients' decision to accept continuous positive airway pressure (CPAP) treatment. DESIGN: Cross-sectional study; patients were recruited between March 2007 and December 2007. SETTING: University-affiliated sleep laboratory. PATIENTS: 162 consecutive newly diagnosed (polysomnographically) adult OSAS patients who required CPAP underwent attendant titration and a 2-week adaptation period. RESULTS: 40% (n = 65) of patients who required CPAP therapy accepted this treatment. Patients accepting CPAP were older, had higher apnea-hypopnea index (AHI) and higher income level, and were more likely to sleep in a separate room than patients declining CPAP treatment. More patients who accepted treatment also reported receiving positive information about CPAP treatment from family or friends. Multiple logistic regression (after adjusting for age, body mass index, Epworth Sleepiness Scale, and AHI) revealed that CPAP purchase is determined by: each increased income level category (OR, 95% CI) (2.4; 1.2-4.6), age + 1 year (1.07; 1.01-1.1), AHI ( > or = 35 vs. < 35 events/hr) (4.2, 1.4-12.0), family and/or friends with positive experience of CPAP (2.9, 1.1-7.5), and partner sleeps separately (4.3, 1.4-13.3). CONCLUSIONS: In addition to the already known determinants of CPAP acceptance, patients with low SES are less receptive to CPAP treatment than groups with higher SES. CPAP support and patient education programs should be better tailored for low SES people in order to increase patient treatment initiation and adherence.