Performance of a reservoir nasal cannula (Oxymizer) during sleep in hypoxemic patients with COPD.

STUDY OBJECTIVE: To determine whether a reservoir nasal cannula (RNC) (Oxymizer) provides an arterial hemoglobin oxygen saturation as measured by pulse oximetry (SpO2) equivalent to that provided by the standard nasal cannula (SNC) during sleep in hypoxemic patients with COPD while reducing oxygen flow requirement and cost. DESIGN: The study took place in a sleep laboratory for three nights, with the first night for acclimatization to the new sleeping environment. In a repeated-measures design, on the second and third nights, subjects used the SNC for one night and the RNC on another night. The order in which they received the two devices was counterbalanced. SUBJECTS: The subjects were patients with COPD who had a stable PaO2 of 55 mm Hg or less or had a value of 56 to 59 mm Hg with evidence of cor pulmonale or polycythemia (or both) and an FEV1/FVC of less than 70 percent. INTERVENTIONS: A pulse oximeter was used to measure SpO2. An arterial blood gas measurement was taken on each night while the patients with COPD were receiving oxygen therapy via the assigned device. An EEG machine was used to record measurements of electro-oculography, chin electromyography (EMG), anterior tibialis EMG and EEG. MEASUREMENTS AND MAIN RESULTS: There was a statistically significant difference between mean SpO2 during sleep (RNC, 91 percent; SNC, 93 percent; F = 7.89; p = 0.01). Nocturnal SpO2 was less than 90 percent for 24.2 percent of the time with the RNC and for 17.5 percent of the time with the SNC (F = 5.41; p = 0.03), but there was no significant difference in the amount of time that SpO2 was less than 85 percent. Compared to the SNC, in 4 of 26 patients with COPD, the RNC performed better; in 12 patients with COPD, the RNC performed the same, and in 10 patients with COPD the RNC performed worse during sleep. Sleep parameters were not significantly different between the two devices. CONCLUSIONS: The difference of 2 percent in mean SpO2 is within the range of SpO2 measurement error. Therefore, the two devices are equally effective when the sample is considered as a whole. Nighttime oximetry is necessary prior to prescription, since nighttime efficacy of the RNC cannot be predicted on the basis of daytime pulse oximetry.

Sleep apnea with unusual EEG changes in Jakob-Creutzfeldt disease.

Disruption of the periodic pattern in the EEG was observed in a patient with Jakob-Creutzfeldt disease. Periods of apnea (during 'sleep') were associated with abrupt cessation of the periodic complexes and their replacement by 7-9 c/sec waves which persisted throughout the apneic episode. The periodic complexes reappeared on termination of the apnea. This close temporal association between disruption of the periodicity and apneic episodes suggests proximity of respiratory neurons and the deep subcortical pacemaker.

Autonomic dysfunction and Eaton Lambert syndrome.

Autonomic dysfunction associated with Eaton Lambert syndrome in a patient with oat cell carcinoma of the lung is reported. Widespread postganglionic adrenergic and cholinergic defects suggested the presence of autonomic neuropathy. Clinical remission accompanied tumor regression after combined chemotherapy and radiation.

A comparison of four treatments for generalized convulsive status epilepticus. Veterans Affairs Status Epilepticus Cooperative Study Group.

BACKGROUND AND METHODS: Although generalized convulsive status epilepticus is a life-threatening emergency, the best initial drug treatment is uncertain. We conducted a five-year randomized, double-blind, multicenter trial of four intravenous regimens: diazepam (0.15 mg per kilogram of body weight) followed by phenytoin (18 mg per kilogram), lorazepam (0.1 mg per kilogram), phenobarbital (15 mg per kilogram), and phenytoin (18 mg per kilogram). Patients were classified as having either overt generalized status epilepticus (defined as easily visible generalized convulsions) or subtle status epilepticus (indicated by coma and ictal discharges on the electroencephalogram, with or without subtle convulsive movements such as rhythmic muscle twitches or tonic eye deviation). Treatment was considered successful when all motor and electroencephalographic seizure activity ceased within 20 minutes after the beginning of the drug infusion and there was no return of seizure activity during the next 40 minutes. Analyses were performed with data on only the 518 patients with verified generalized convulsive status epilepticus as well as with data on all 570 patients who were enrolled. RESULTS: Three hundred eighty-four patients had a verified diagnosis of overt generalized convulsive status epilepticus. In this group, lorazepam was successful in 64.9 percent of those assigned to receive it, phenobarbital in 58.2 percent, diazepam plus phenytoin in 55.8 percent, and phenytoin in 43.6 percent (P=0.02 for the overall comparison among the four groups). Lorazepam was significantly superior to phenytoin in a pairwise comparison (P=0.002). Among the 134 patients with a verified diagnosis of subtle generalized convulsive status epilepticus, no significant differences among the treatments were detected (range of success rates, 7.7 to 24.2 percent). In an intention-to-treat analysis, the differences among treatment groups were not significant, either among the patients with overt status epilepticus (P=0.12) or among those with subtle status epilepticus (P=0.91). There were no differences among the treatments with respect to recurrence during the 12-hour study period, the incidence of adverse reactions, or the outcome at 30 days. CONCLUSIONS: As initial intravenous treatment for overt generalized convulsive status epilepticus, lorazepam is more effective than phenytoin. Although lorazepam is no more efficacious than phenobarbital or diazepam plus phenytoin, it is easier to use.