Sleep Apnea Syndromes: Chesson AL

Morgenthaler TI, Aurora RN, Brown T, Zak R, Alessi C, Boehlecke B, Chesson AL, Friedman L, Kapur V, Maganti R, Owens J, Pancer J, Swick TJ, Anonymous00064, Anonymous00065. · Mayo Clinic, Rochester MN, USA. · Sleep. · Pubmed #18220088 links to  free full text

Abstract: These practice parameters are an update of the previously published recommendations regarding the use of autotitrating positive airway pressure (APAP) devices for titrating pressures and treating adult patients with obstructive sleep apnea syndrome. Continuous positive airway pressure (CPAP) at an effective setting verified by attended polysomnography is a standard treatment for obstructive sleep apnea (OSA). APAP devices change the treatment pressure based on feedback from various patient measures such as airflow, pressure fluctuations, or measures of airway resistance. These devices may aid in the pressure titration process, address possible changes in pressure requirements throughout a given night and from night to night, aid in treatment of OSA when attended CPAP titration has not or cannot be accomplished, or improve patient comfort. A task force of the Standards of Practice Committee of the American Academy of Sleep Medicine has reviewed the literature published since the 2002 practice parameter on the use of APAP. Current recommendations follow: (1) APAP devices are not recommended to diagnose OSA; (2) patients with congestive heart failure, patients with significant lung disease such as chronic obstructive pulmonary disease; patients expected to have nocturnal arterial oxyhemoglobin desaturation due to conditions other than OSA (e.g., obesity hypoventilation syndrome); patients who do not snore (either naturally or as a result of palate surgery); and patients who have central sleep apnea syndromes are not currently candidates for APAP titration or treatment; (3) APAP devices are not currently recommended for split-night titration; (4) certain APAP devices may be used during attended titration with polysomnography to identify a single pressure for use with standard CPAP for treatment of moderate to severe OSA; (5) certain APAP devices may be initiated and used in the self-adjusting mode for unattended treatment of patients with moderate to severe OSA without significant comorbidities (CHF, COPD, central sleep apnea syndromes, or hypoventilation syndromes); (6) certain APAP devices may be used in an unattended way to determine a fixed CPAP treatment pressure for patients with moderate to severe OSA without significant comorbidities (CHF, COPD, central sleep apnea syndromes, or hypoventilation syndromes); (7) patients being treated with fixed CPAP on the basis of APAP titration or being treated with APAP must have close clinical follow-up to determine treatment effectiveness and safety; and (8) a reevaluation and, if necessary, a standard attended CPAP titration should be performed if symptoms do not resolve or the APAP treatment otherwise appears to lack efficacy.

Chesson AL, Berry RB, Pack A, Anonymous00016, Anonymous00017, Anonymous00018. · Louisiana State University Health Sciences Center-Shreveport, Shreveport, Louisiana, USA. · Sleep. · Pubmed #14655928 No free full text.

Abstract: BACKGROUND: A variety of devices are used to evaluate patients with a potential diagnosis of obstructive sleep apnea (OSA). A committee comprised of members of the American Academy of Sleep Medicine, American Thoracic Society, and American College of Chest Physicians systematically evaluated data on the use of these devices and developed practice parameters. DEVICES REVIEWED: Three categories of portable monitoring (PM) devices were reviewed with regard to assessing the probability of identifying an apnea-hypopnea index (AHI) of greater or less than 15 in attended and unattended settings. Type 2 (minimum of seven channels, including EEG, EOG, chin EMG, ECG or heart rate, airflow, respiratory effort, oxygen saturation), Type 3 (minimum of four channels, including ventilation or airflow (at least two channels of respiratory movement, or respiratory movement and airflow), heart rate or ECG and oxygen saturation) and Type 4 (most monitors of this type measure a single parameter or two parameters) devices were evaluated, and in-laboratory, attended polysomnography was used as a reference. SPECIFIC RECOMMENDATIONS: (1) Insufficient evidence is available to recommend the use of Type 2 PM devices in attended or unattended settings. (2) Type 3 PM devices appear to be capable of being used in an attended setting to increase or to decrease the probability that a patient has an apnea-hypopnea index greater than 15. (3) The use of Type 3 PM devices in an unattended setting is not recommended to rule in, rule out, or both rule in and rule out a diagnosis of OSA. (4) There is some evidence that the use of Type 3 PM devices in an attended in-laboratory setting may be acceptable to both rule in and rule out a diagnosis of OSA if certain limitations are in place. These limitations include manually scoring the records, using the devices only in patients without significant comorbid conditions, having an awareness that symptomatic patients with a negative study should have a Type 1 study, and not using these devices for titrating positive airway pressure or conducting split-night studies. (5) The use of Type 4 PM devices in attended or unattended settings is not recommended. GENERAL RECOMMENDATIONS: Type 3 and 4 PM devices cannot score sleep and, therefore, do not meet some current Medicare guidelines. The use of PM devices is not recommended for general-population screening or in the absence of a pretest probability of the patient having a diagnosis of OSA, for complaints other than those associated with OSA, without review of raw data during interpretation, by physicians without familiarity with their use and limitations, and without trained personnel to perform technical scoring. Future research should address the use of PM devices in patients with comorbid conditions; non-White patients and women; larger, better-controlled studies; studies focused on the use of Type 2 and 3 devices; studies focusing on decision making and outcomes rather than simple classification using arbitrary cutoffs; and studies that seek to elucidate cost-effectiveness data on the use of PM devices.

Bonnet MH, Doghramji K, Roehrs T, Stepanski EJ, Sheldon SH, Walters AS, Wise M, Chesson AL. · Dayton Department of Veterans Affairs Medical Center, OH 45428, USA. · J Clin Sleep Med. · Pubmed #17557423 No free full text.

Abstract: The reliability and validity of EEG arousals and other types of arousal are reviewed. Brief arousals during sleep had been observed for many years, but the evolution of sleep medicine in the 1980s directed new attention to these events. Early studies at that time in animals and humans linked brief EEG arousals and associated fragmentation of sleep to daytime sleepiness and degraded performance. Increasing interest in scoring of EEG arousals led the ASDA to publish a scoring manual in 1992. The current review summarizes numerous studies that have examined scoring reliability for these EEG arousals. Validity of EEG arousals was explored by review of studies that empirically varied arousals and found deficits similar to those found after total sleep deprivation depending upon the rate and extent of sleep fragmentation. Additional data from patients with clinical sleep disorders prior to and after effective treatment has also shown a continuing relationship between reduction in pathology-related arousals and improved sleep and daytime function. Finally, many suggestions have been made to refine arousal scoring to include additional elements (e.g., CAP), change the time frame, or focus on other physiological responses such as heart rate or blood pressure changes. Evidence to support the reliability and validity of these measures is presented. It was concluded that the scoring of EEG arousals has added much to our understanding of the sleep process but that significant work on the neurophysiology of arousal needs to be done. Additional refinement of arousal scoring will provide improved insight into sleep pathology and recovery.

Hoque R, Schwendimann RN, Liendo C, Chesson AL. · Department of Neurology, Louisiana State University Health Sciences Center, Shreveport, LA 71130, USA. · J Clin Neuromuscul Dis. · Pubmed #18525424 No free full text.

Abstract: We present a case of supine respiratory failure due to a bilateral diaphragmatic paralysis associated with brachial neuritis secondary to thoracic herpes zoster. Fluoroscopy in both the standing and supine positions revealed bilateral diaphragmatic paralysis accentuated in the supine position. To our knowledge, this is the first case of thoracic herpes zoster associated with brachial neuritis and bilateral diaphragmatic paralysis.

Richards KC, Anderson WM, Chesson AL, Nagel CL. · Central Arkansas Veterans Healthcare System, and University of Arkansas for Medical Sciences, College of Nursing, Little Rock, USA. · J Cardiovasc Nurs. · Pubmed #12358092 No free full text.

Abstract: This descriptive study describes the frequency and severity of sleep-related breathing disorders in men who are hemodynamically stable who have an acute cardiovascular illness and are hospitalized in a critical care unit. Sixty-four males, aged 55-79 years, with an acute cardiovascular illness, stable hemodynamics, and no ongoing chest pain or history of sleep apnea were studied for 1 night in the critical care unit using polysomnography. Forty-seven percent of the sample had an apnea-hypopnea index > or = 5, with events of both obstructive and central etiologies, including Cheyne-Stokes respiration. Oxygen desaturation to < or = 90% occurred in 61% of the sample. There were no episodes of chest pain, ventricular tachycardia, or heart block associated with apneic or hypopneic events; however, dysrhythmias, including sinus bradycardia, supraventricular tachycardia, and premature ventricular beats, were associated with apneic and hypopneic events.

Murphy PW, Chesson AL, Walker L, Arnold CL, Chesson LM. · Department of Medicine, Louisiana State University Health Sciences Center-Shreveport, 71130-3932, USA. · South Med J. · Pubmed #10728518 No free full text.

Abstract: BACKGROUND: Health care professionals often use written material or video recordings to teach their patients without knowing which is more effective for comprehension of the information. METHODS: Patients watched either an instructional videotape about sleep apnea or read a newly designed brochure, then responded to a structured questionnaire containing 11 knowledge-based questions and 1 open-ended question (requesting suggestions for improvement of the brochure or videotape). RESULTS: Mean reported educational level was grade 12, and mean reading level was between grade 7 and 8. Using video significantly improved only two areas of knowledge for low-level (below grade 8) readers: defining sleep apnea (66% vs 43%) and identifying what continuous positive airway pressure (CPAP) does for the patient (94% vs 78%). Patients requested material with more diverse cultural representation, more information on treatment and outcomes, and fewer polysyllabic words. CONCLUSIONS: Emphasis on diagnosis and treatment, explained using simple words, should be reflected in the content of patient education brochures or videos. Providing information by video alone may have limited benefits.