Executive Summary: Optimal NIV Medicare Access Promotion: A Technical Expert Panel Report From the American College of Chest Physicians, the American Association for Respiratory Care, the American Academy of Sleep Medicine, and the American Thoracic Society.

The current national coverage determinations (NCDs) for noninvasive ventilation for patients with thoracic restrictive disorders, COPD, and hypoventilation syndromes were formulated in 1998. New original research, updated formal practice guidelines, and current consensus expert opinion have accrued that are in conflict with the existing NCDs. Some inconsistencies in the NCDs have been noted, and the diagnostic and therapeutic technology has also advanced in the last quarter century. Thus, these and related NCDs relevant to bilevel positive airway pressure for the treatment of OSA and central sleep apnea need to be updated to ensure the optimal health of patients with these disorders. To that end, the American College of Chest Physicians organized a multisociety (American Thoracic Society, American Academy of Sleep Medicine, and American Association for Respiratory Care) effort to engage experts in the field to: (1) identify current barriers to optimal care; (2) highlight compelling scientific evidence that would justify changes from current policies incorporating best evidence and practice; and (3) propose suggestions that would form the basis for a revised NCD in each of these 5 areas (thoracic restrictive disorders, COPD, hypoventilation syndromes, OSA, and central sleep apnea). The expert panel met during a 2-day virtual summit in October 2020 and subsequently crafted written documents designed to achieve provision of "the right device to the right patient at the right time." These documents have been endorsed by the participating societies following peer review and publication in CHEST and will be used to inform efforts to revise the current NCDs.

Optimal NIV Medicare Access Promotion: Patients With Hypoventilation Syndromes: A Technical Expert Panel Report From the American College of Chest Physicians, the American Association for Respiratory Care, the American Academy of Sleep Medicine, and the American Thoracic Society.

The existing coverage criteria for home noninvasive ventilation (NIV) do not recognize the diversity of hypoventilation syndromes and advances in technologies. This document summarizes the work of the hypoventilation syndromes Technical Expert Panel working group. The most pressing current coverage barriers identified were: (1) overreliance on arterial blood gases (particularly during sleep); (2) need to perform testing on prescribed oxygen; (3) requiring a sleep study to rule out OSA as the cause of sustained hypoxemia; (4) need for spirometry; (5) need to show bilevel positive airway pressure (BPAP) without a backup rate failure to qualify for BPAP spontaneous/timed; and (6) qualifying hospitalized patients for home NIV therapy at the time of discharge. Critical evidence support for changes to current policies includes randomized controlled trial evidence and clinical practice guidelines. To decrease morbidity and mortality by achieving timely access to NIV for patients with hypoventilation, particularly those with obesity hypoventilation syndrome, we make the following key suggestions: (1) given the significant technological advances, we advise acceptance of surrogate noninvasive end-tidal and transcutaneous Pco2 and venous blood gases in lieu of arterial blood gases; (2) not requiring Pco2 measures while on prescribed oxygen; (3) not requiring a sleep study to avoid delays in care in patients being discharged from the hospital; (4) remove spirometry as a requirement; and (5) not requiring BPAP without a backup rate failure to approve BPAP spontaneous/timed. The overarching goal of the Technical Expert Panel is to establish pathways that improve clinicians' management capability to provide Medicare beneficiaries access to appropriate home NIV therapy. Adoption of these proposed suggestions would result in the right device, for the right type of patient with hypoventilation syndromes, at the right time.

Screening for early symptoms of respiratory involvement in myotonic dystrophy type 1 using the Respicheck questionnaire.

Symptoms of respiratory involvement are frequently present but overlooked by patients with Myotonic Dystrophy type 1 (DM1). A respiratory symptom checklist was designed to test whether a DM-specifically designed checklist to detect symptoms of respiratory involvement (The Respicheck Questionnaire) could help patients be more aware of their respiratory problems, if any, and help clinicians in identifying potential candidates for intervention. The Respicheck questionnaire was administered to 58 consecutive adult-onset patients with genetically determined DM1 who did not complain of respiratory involvement per history at enrollment. Based on respiratory function test results patients were divided into 3 groups: A, (n = 17) having no signs of respiratory involvement; B (n = 13), patients having borderline results on respiratory assessments and having no need for respiratory intervention; C, (n = 28) patients having respiratory impairment requiring intervention. Respiratory test results and Respicheck scores were analyzed. Respicheck total score and subscales correlated positively with global respiratory impairment. Respicheck appears to be able to discriminate between patients having a higher level of respiratory dysfunction from those having a lower risk of respiratory involvement. This might allow to better target efforts and resources in respiratory management in DM1.

Relevance of lung ultrasound in the diagnostic algorithm of respiratory diseases in a real-life setting: A multicentre prospective study.

BACKGROUND AND OBJECTIVE: The aim of this study was to assess the role of lung ultrasound (LUS) in a diagnostic algorithm of respiratory diseases, and to establish the accuracy of LUS compared with chest radiography (CXR). METHODS: Over a period of 2 years, 509 consecutive patients admitted for respiratory-related symptoms to both emergency and general medicine wards were enrolled and evaluated using LUS and CXR. LUS was conducted by expert operators who were blinded to the medical history and laboratory data. Computed tomography (CT) of the chest was performed in case of discordance between the CXR and LUS, suspected lung cancer and an inconclusive diagnosis. Diagnosis made by CT was considered the gold standard. RESULTS: The difference in sensitivity and specificity between LUS and CXR as demonstrated by ROC curve analyses (LUS-AUROC: 0.853; specificity: 81.6%; sensitivity: 93.9% vs CXR-AUROC: 0.763; specificity: 57.4%; sensitivity: 96.3%) was significant (P = 0.001). Final diagnosis included 240 cases (47.2%) of pneumonia, 44 patients with cancer (8.6%), 20 patients with chronic obstructive pulmonary disease (COPD, 3.9%), 24 patients with heart failure (4.7%) and others (6.1%). In 108 patients (21.2%) with any lung pathology, a CT scan was performed with a positive diagnosis in 96 cases (88.9%); we found that CXR and LUS detected no abnormality in 24 (25%) and 5 (5.2%) cases, respectively. LUS was concordant with the final diagnosis (P < 0.0001), and in healthy patients, there was a low percentage of false positives (5.9%). CONCLUSION: The results support the routine use of LUS in the clinical context.

Respiratory subtype of panic disorder: Can serum phosphate levels be a possible outcome to group cognitive-behavior therapy?

OBJECTIVE: Panic disorder (PD) respiratory subtype (RS) was described in order to cluster patients according to their symptoms. These patients are characterized by experiencing a relatively high number of noticeable respiratory symptoms during a panic attack (PA) and a higher reactivity to CO2. In this study, we aimed to evaluate the clinical relevance of this diagnostic category, evaluating if there are different responses to cognitive-behavioral therapy in patients with panic disorder RS as compared to those with the non-respiratory subtype (NRS), using serum phosphate as a biological marker. METHODS: Patients were assessed by a clinical interview followed by a structured diagnostic interview (M.I.N.I) and classified as RS or NRS based on symptoms. The severity of PD was evaluated throughout the PDSS, CGI, HAM-A, STAI and the BDI rating scales. All patients underwent 12 structured sessions of group-CBT for PD and had their blood collected at baseline and after treatment to assess phosphate levels. RESULTS: One hundred and thirty-eight patients have been assessed, and 102 were included in this trial. Sixty-nine patients completed the treatment protocol, 42 were classified as RS and 27 as NRS. Both RS and NRS patients improved in all clinical scales (p < 0.001). The mean phosphate levels increased from 2.44 mg/dl ±â€¯0.49 at baseline to 3.38 mg/dl ±â€¯0.52 (p < 0.01) in the RS group as well as from 2.46 mg/dl ±â€¯0.64 at baseline to 3.46 mg/dl ±â€¯0.61 (p < 0.01) in the NSR group. LIMITATIONS: Small sample size and the lack of assessment of other clinical and physiological parameters, such as respiratory variables. CONCLUSION: Our findings suggest that both RS and NRS benefit from group CBT and that there was a change in phosphate levels after effective treatment in both groups. Our data support the idea that there is a reversal of the conditions that promote hypophosphatemia as chronic hyperventilation after CBT treatment, whereas it is in disagreement to the presence of two different PD subtypes based on phosphate levels once their rates did not differ at baseline and had a similar increase after effective treatment.

Episodic Laryngeal Breathing Disorders: Literature Review and Proposal of Preliminary Theoretical Framework.

OBJECTIVE: The purposes of this literature review were (1) to identify and assess frameworks for clinical characterization of episodic laryngeal breathing disorders (ELBD) and their subtypes, (2) to integrate concepts from these frameworks into a novel theoretical paradigm, and (3) to provide a preliminary algorithm to classify clinical features of ELBD for future study of its clinical manifestations and underlying pathophysiological mechanisms. STUDY DESIGN: This is a literature review. METHODS: Peer-reviewed literature from 1983 to 2015 pertaining to models for ELBD was searched using Pubmed, Ovid, Proquest, Cochrane Database of Systematic Reviews, and Google Scholar. Theoretical models for ELBD were identified, evaluated, and integrated into a novel comprehensive framework. Consensus across three salient models provided a working definition and inclusionary criteria for ELBD within the new framework. Inconsistencies and discrepancies within the models provided an analytic platform for future research. RESULTS: Comparison among three conceptual models-(1) Irritable larynx syndrome, (2) Dichotomous triggers, and (3) Periodic occurrence of laryngeal obstruction-showed that the models uniformly consider ELBD to involve episodic laryngeal obstruction causing dyspnea. The models differed in their description of source of dyspnea, in their inclusion of corollary behaviors, in their inclusion of other laryngeal-based behaviors (eg, cough), and types of triggers. CONCLUSION: The proposed integrated theoretical framework for ELBD provides a preliminary systematic platform for the identification of key clinical feature patterns indicative of ELBD and associated clinical subgroups. This algorithmic paradigm should evolve with better understanding of this spectrum of disorders and its underlying pathophysiological mechanisms.

Dysfunctional breathing: a review of the literature and proposal for classification.

Dysfunctional breathing is a term describing breathing disorders where chronic changes in breathing pattern result in dyspnoea and other symptoms in the absence or in excess of the magnitude of physiological respiratory or cardiac disease. We reviewed the literature and propose a classification system for the common dysfunctional breathing patterns described. The literature was searched using the terms: dysfunctional breathing, hyperventilation, Nijmegen questionnaire and thoraco-abdominal asynchrony. We have summarised the presentation, assessment and treatment of dysfunctional breathing, and propose that the following system be used for classification. 1) Hyperventilation syndrome: associated with symptoms both related to respiratory alkalosis and independent of hypocapnia. 2) Periodic deep sighing: frequent sighing with an irregular breathing pattern. 3) Thoracic dominant breathing: can often manifest in somatic disease, if occurring without disease it may be considered dysfunctional and results in dyspnoea. 4) Forced abdominal expiration: these patients utilise inappropriate and excessive abdominal muscle contraction to aid expiration. 5) Thoraco-abdominal asynchrony: where there is delay between rib cage and abdominal contraction resulting in ineffective breathing mechanics.This review highlights the common abnormalities, current diagnostic methods and therapeutic implications in dysfunctional breathing. Future work should aim to further investigate the prevalence, clinical associations and treatment of these presentations.

Neonatal ventilatory support and respiratory diseases in children up to six years of age: the 2004 Pelotas (Brazil) Birth Cohort study.

The study's objective was to evaluate the association between neonatal ventilatory support and the subsequent occurrence of respiratory diseases in children up to six years of age. This was a population-based birth cohort study. The main exposure was ventilatory support at birth, defined as the use of nasal continuous positive airway pressure (NCPAP) and/or mechanical ventilation (MV) for more than three hours from the time of hospitalization at birth until the first 28 days of life. Outcomes were: chest wheezing in the twelve months prior to the follow-up interview, medical diagnosis of asthma any time in the child´s life, and occurrence of pneumonia up to six years of age. Crude and adjusted analyses for potential confounding variables were performed using Poisson regression. 3,624 children were analyzed. NCPAP plus MV or MV alone was associated with higher frequency of medical diagnosis of asthma, even after adjusting for maternal and child characteristics (PR = 2.24; 95%CI: 1.27-3.99). The results highlight medium-term respiratory complications associated with neonatal ventilatory support.

Suporte ventilatório ao nascer e associação com doenças respiratórias aos seis anos: Coorte de Nascimentos de Pelotas, Rio Grande do Sul, Brasil, 2004 / Soporte ventilatorio en el período neonatal y enfermedades respiratorias en los seis primeros años de vida: Cohorte de Nacimientos de Pelotas, Rio Grande do Sul, Brasil, 2004 / Neonatal ventilatory support and respiratory diseases in children up to six years of age: the 2004 Pelotas (Brazil) Birth Cohort study

O objetivo do estudo foi avaliar a associação entre suporte ventilatório no período neonatal e doenças respiratórias até os seis anos de idade. Estudo de coorte de nascimentos de base populacional. A exposição principal foi o suporte ventilatório ao nascimento, definido como o uso de pressão contínua positiva nasal (CPAPn) e/ou ventilação mecânica (VM) por mais de três horas, desde o momento da hospitalização ao nascimento até os 28 dias. Os desfechos foram chiado no peito nos últimos 12 meses, diagnóstico médico de asma alguma vez na vida e episódio de pneumonia ocorrido até os seis anos de idade. Foram realizadas análises brutas e ajustadas para potenciais variáveis de confusão, usando regressão de Poisson. Foram analisadas 3.624 crianças. O uso de CPAPn e VM ou unicamente VM esteve associado com maior frequência de diagnóstico médico de asma, mesmo após ajuste para características maternas e das crianças (RP = 2,24; IC95%: 1,27-3,99). Os resultados do presente estudo alertam para as complicações respiratórias, em médio prazo, decorrentes do suporte ventilatório realizado no período neonatal.

El objetivo del estudio fue evaluar la asociación entre el soporte ventilatorio durante el período neonatal y las enfermedades respiratorias durante los seis primeros años de vida. Se trata de un estudio de cohorte de nacimiento con base poblacional. La exposición principal, soporte ventilatorio al nacimiento, fue definida como el uso de presión positiva nasal (CPAPn) y/o ventilación mecánica (VM) durante más de tres horas, desde la hospitalización al nacimiento, hasta los 28 días de vida. Los resultados analizados fueron: broncoespasmo en los últimos doce meses, diagnóstico médico de asma - realizado alguna vez en la vida- y episodio de neumonía ocurrido hasta los seis años de edad. Se realizaron análisis brutos y ajustados para potenciales variables de confusión, usando la regresión de Poisson. Fueron estudiados 3.624 niños. El uso de soporte ventilatorio estuvo asociado con una mayor frecuencia de diagnóstico médico de asma, incluso tras ajustar las características maternas y de los niños (RP = 2,24; IC95%: 1,27-3,99). Los resultados alertan sobre las complicaciones respiratorias a medio plazo tras el soporte ventilatorio realizado en el período neonatal.

The study's objective was to evaluate the association between neonatal ventilatory support and the subsequent occurrence of respiratory diseases in children up to six years of age. This was a population-based birth cohort study. The main exposure was ventilatory support at birth, defined as the use of nasal continuous positive airway pressure (NCPAP) and/or mechanical ventilation (MV) for more than three hours from the time of hospitalization at birth until the first 28 days of life. Outcomes were: chest wheezing in the twelve months prior to the follow-up interview, medical diagnosis of asthma any time in the child´s life, and occurrence of pneumonia up to six years of age. Crude and adjusted analyses for potential confounding variables were performed using Poisson regression. 3,624 children were analyzed. NCPAP plus MV or MV alone was associated with higher frequency of medical diagnosis of asthma, even after adjusting for maternal and child characteristics (PR = 2.24; 95%CI: 1.27-3.99). The results highlight medium-term respiratory complications associated with neonatal ventilatory support.

Risk factors for respiratory complications after adenotonsillectomy in children with obstructive sleep apnea / Fatores de risco para complicações respiratórias após adenotonsilectomia em crianças com apneia obstrutiva do sono

Objective: To identify risk factors for respiratory complications after adenotonsillectomy in children ≤ 12 years of age with obstructive sleep apnea who were referred to the pediatric ICU (PICU). Methods: A cross-sectional historical cohort study analyzing 53 children after adenotonsillectomy who met predetermined criteria for PICU referral in a tertiary level teaching hospital. The Student's t-test, Mann-Whitney test, and chi-square test were used to identify risk factors. Results: Of the 805 children undergoing adenotonsillectomy between January of 2006 and December of 2012 in the teaching hospital, 53 were referred to the PICU. Twenty-one children (2.6% of all those undergoing adenotonsillectomy and 39.6% of those who were referred to the PICU) had respiratory complications. Of those 21, 12 were male. The mean age was 5.3 ± 2.6 years. A high apnea-hypopnea index (AHI; p = 0.0269), a high oxygen desaturation index (ODI; p = 0.0082), a low SpO2 nadir (p = 0.0055), prolonged orotracheal intubation (p = 0.0011), and rhinitis (p = 0.0426) were found to be independent predictors of respiratory complications. Some of the complications observed were minor (SpO2 90-80%), whereas others were major (SpO2 ≤ 80%, laryngospasm, bronchospasm, acute pulmonary edema, pneumonia, and apnea). Conclusions: Among children up to 12 years of age with OSA, those who have a high AHI, a high ODI, a low SpO2 nadir, or rhinitis are more likely to develop respiratory complications after adenotonsillectomy than are those without such characteristics. .

Objetivo: Identificar fatores de risco para complicações respiratórias após adenotonsilectomia em crianças ≤ 12 anos com apneia obstrutiva do sono encaminhadas à UTI pediátrica (UTIP). Métodos: Estudo de coorte histórica com corte transversal que analisou 53 crianças após adenotonsilectomia que preencheram os critérios pré-estabelecidos para encaminhamento à UTIP em um hospital escola de nível terciário. Foram utilizados o teste t de Student, o teste de Mann-Whitney e o teste do qui-quadrado para identificar os fatores de risco. Resultados: Das 805 crianças submetidas à adenotonsilectomia entre janeiro de 2006 e dezembro de 2012 no hospital escola, 53 foram encaminhadas à UTIP. Vinte e uma crianças (2,6% do total de submetidas à adenotonsilectomia e 39,6% das que foram encaminhadas à UTIP) apresentaram complicações respiratórias, sendo 12 do gênero masculino e a idade média de 5,3 ± 2,6 anos. Maior índice de apneia-hipopneia (IAH; p = 0,0269), maior índice de dessaturação de oxigênio (IDO; p = 0,0082), baixo nadir da SpO2 (p = 0,0055), maior tempo de intubação orotraqueal (p = 0,0011) e rinopatia (p = 0,0426) foram preditores independentes de complicações respiratórias. Foram observadas complicações respiratórias menores (SpO2 entre 90-80%) e maiores (SpO2 ≤ 80%, laringoespasmos, broncoespasmos, edema agudo de pulmão, pneumonia e apneia). Conclusões: Em crianças de até 12 anos e com apneia obstrutiva do sono, aquelas que têm maior IAH, maior IDO, menor nadir da SpO2 e/ou rinopatia são mais predispostas a desenvolver complicações respiratórias após adenotonsilectomia do que aquelas sem essas características. .

Laboratory, clinical and therapeutic features of respiratory panic disorder subtype.

OBJECTIVE: It is our aim to elaborate on the new developments in regard to the respiratory subtype (RS) of panic disorder (PD) since it was first described. We will present psychopathological features, diagnostic criteria, genetic and physiopathological hypotheses, as well as therapeutic and prognostic characteristics. METHOD: Two searches were performed in the Thomson Reuters Web of Knowledge (http://wokinfo.com/): 1 - search terms: "panic disorder" AND ("respiratory symptom" OR "respiratory symptoms" OR "respiratory subtype" OR "respiratory panic" OR "cardiorespiratory"); 2 - all articles citing Briggs and colleagues' 1993 article "Subtyping of Panic Disorder by Symptom Profile" (Br J Psychiatry 1993;163: 201-9). Only those articles involving human subjects and written English were included. RESULTS: In comparison with patients of the non-respiratory subtype (NRS), RS patients showed greater familial history of PD, and higher comorbidity rates for anxiety disorders and depressive disorders. These patients were also more sensitive to CO2, hyperventilation and caffeine. CONCLUSION: Certain characteristics, such as heightened sensitivity to CO2 and the higher incidence of a family history of PD, clearly distinguished the Respiratory Subtype patients from the Non-Respiratory. Nonetheless, some studies failed to demonstrate differential responses to pharmacological treatment and CBT across the subtypes. RS patients seem to respond faster than NRS to pharmacological treatment with antidepressants and benzodiazepines, but more studies are needed to confirm this finding.

Multidisciplinary Modelling of Symptoms and Signs with Archetypes and SNOMED-CT for Clinical Decision Support.

Clinical Decision Support Systems (CDSS) help to improve health care and reduce costs. However, the lack of knowledge management and modelling hampers their maintenance and reuse. Current EHR standards and terminologies can allow the semantic representation of the data and knowledge of CDSS systems boosting their interoperability, reuse and maintenance. This paper presents the modelling process of respiratory conditions' symptoms and signs by a multidisciplinary team of clinicians and information architects with the help of openEHR, SNOMED and clinical information modelling tools for a CDSS. The information model of the CDSS was defined by means of an archetype and the knowledge model was implemented by means of an SNOMED-CT based ontology.

Risk factors for respiratory complications after adenotonsillectomy in children with obstructive sleep apnea.

OBJECTIVE: To identify risk factors for respiratory complications after adenotonsillectomy in children ≤ 12 years of age with obstructive sleep apnea who were referred to the pediatric ICU (PICU). METHODS: A cross-sectional historical cohort study analyzing 53 children after adenotonsillectomy who met predetermined criteria for PICU referral in a tertiary level teaching hospital. The Student's t-test, Mann-Whitney test, and chi-square test were used to identify risk factors. RESULTS: Of the 805 children undergoing adenotonsillectomy between January of 2006 and December of 2012 in the teaching hospital, 53 were referred to the PICU. Twenty-one children (2.6% of all those undergoing adenotonsillectomy and 39.6% of those who were referred to the PICU) had respiratory complications. Of those 21, 12 were male. The mean age was 5.3 ± 2.6 years. A high apnea-hypopnea index (AHI; p = 0.0269), a high oxygen desaturation index (ODI; p = 0.0082), a low SpO2 nadir (p = 0.0055), prolonged orotracheal intubation (p = 0.0011), and rhinitis (p = 0.0426) were found to be independent predictors of respiratory complications. Some of the complications observed were minor (SpO2 90-80%), whereas others were major (SpO2 ≤ 80%, laryngospasm, bronchospasm, acute pulmonary edema, pneumonia, and apnea). CONCLUSIONS: Among children up to 12 years of age with OSA, those who have a high AHI, a high ODI, a low SpO2 nadir, or rhinitis are more likely to develop respiratory complications after adenotonsillectomy than are those without such characteristics.

Recommendations for fitness for work medical evaluations in chronic respiratory patients. Spanish Society of Pulmonology and Thoracic Surgery (SEPAR).

Chronic respiratory diseases often cause impairment in the functions and/or structure of the respiratory system, and impose limitations on different activities in the lives of persons who suffer them. In younger patients with an active working life, these limitations can cause problems in carrying out their normal work. Article 41 of the Spanish Constitution states that «the public authorities shall maintain a public Social Security system for all citizens guaranteeing adequate social assistance and benefits in situations of hardship¼. Within this framework is the assessment of fitness for work, as a dual-nature process (medico-legal) that aims to determine whether it is appropriate or not to recognise a person's right to receive benefits which replace the income that they no longer receive as they cannot carry out their work, due to loss of health. The role of the pulmonologist is essential in evaluating the diagnosis, treatment, prognosis and functional capacity of respiratory patients. These recommendations seek to bring the complex setting of fitness for work evaluation to pulmonologists and thoracic surgeons, providing action guidelines that allow them to advise their own patients about their incorporation into working life.