Positional Therapy in a Patient With Refractory Treatment-Emergent Central Sleep Apnea

Treatment-emergent central sleep apnea (TE-CSA) is commonly encountered during the treatment for obstructive sleep apnea (OSA) with positive airway pressure (PAP) and usually remains self-limited. Persistent TE-CSA is sporadically seen with PAP therapy and has only rarely been described with hypoglossal nerve stimulation (HGNS). We report the case of a 60-year-old female patient with moderate OSA that progressed to TE-CSA with PAP therapy. A prolonged trial with PAP therapy was limited because the patient experienced recurrent aerophagia and subsequently underwent HGNS implantation. HGNS titration led to improved control of the patient’s OSA, but TE-CSA recurred and demonstrated a strong positional component. Lateral positional therapy was implemented with adequate control of respiratory events. TE-CSA can persist throughout different treatment modalities, including HGNS. The patient’s successful lateral sleep therapy for persistent and positionally exacerbated TE-CSA demonstrates the benefit of a well-known sleep apnea treatment for this poorly understood condition.

SleepPos App: An Automated Smartphone Application for Angle Based High Resolution Sleep Position Monitoring and Treatment

Poor sleep quality or disturbed sleep is associated with multiple health conditions. Sleep position affects the severity and occurrence of these complications, and positional therapy is one of the less invasive treatments to deal with them. Sleep positions can be self-reported, which is unreliable, or determined by using specific devices, such as polysomnography, polygraphy or cameras, that can be expensive and difficult to employ at home. The aim of this study is to determine how smartphones could be used to monitor and treat sleep position at home. We divided our research into three tasks: (1) develop an Android smartphone application (‘SleepPos’ app) which monitors angle-based high-resolution sleep position and allows to simultaneously apply positional treatment; (2) test the smartphone application at home coupled with a pulse oximeter; and (3) explore the potential of this tool to detect the positional occurrence of desaturation events. The results show how the ‘SleepPos’ app successfully determined the sleep position and revealed positional patterns of occurrence of desaturation events. The ‘SleepPos’ app also succeeded in applying positional therapy and preventing the subjects from sleeping in the supine sleep position. This study demonstrates how smartphones are capable of reliably monitoring high-resolution sleep position and provide useful clinical information about the positional occurrence of desaturation events.

Proning During Pandemic: The Rapid Institution of a Safe, Transferable, and Effective Prone Positioning Program at Nychhc/elmhurst Hospital, A Situationally Resource Limited Facility, During the Peak of the Covid 19 Surge

Introduction:The use of prone positional therapy for moderate and severe hypoxicAcute Respiratory Distress Syndrome (ARDS) is known to decrease mortality. There are barriers to the routine use of Intermittent Prone Positioning (IPP), yet medical facilities are being overwhelmed with hypoxic patients due to COVID 19. We present the evolution of a high reliability protocolized program for IPP using minimal materials at the peak of the surge of COVID 19 patients that is applicable in settings of significant limitations and austerity.Methods:In the second week of April 2020 the program evolved through a series of short loop quality-based changes based in the principles of High Reliability Organizations (HROs) and Crew Resource Management (CRM). Patients with moderate to severe ARDS [PaO2:FiO2 ratio (PFr) was < 150 on an FiO2> 0.6 and a PEEP > 5 cm H2O] were eligible to receive IPP.The prone team consists of five to seven persons and patients were placed in the prone position for 16 hours and supine for 8 hours each day. When their PFr was > 200 for > 8 hours supine, positional therapy ceased. Patients were positioned prone using only available materials without additional work from the bedside physicians, registered nurses (RNs) or respiratory therapists (RTs).Arterial blood gases (ABGs) provided the measures of PaO2, PaCO2 and FiO2 and enabled calculation of the PFr and the SaO2:FiO2 ratio (SaFr). Data were collected concurrently by prospective intention for quality assessment. Data are reported as number (n) and percent (%) or mean ± standard error of the mean (SEM) and range. Changes in PaCO2, PF ratios, and SaF ratios are made by paired sample t-tests (2-tailed). Associations of PFr and SaFr at one hour pre-prone are evaluated using Pearson’s correlation and simple linear regression. Data were evaluated using R® Version 1.2.1335 (R Foundation for Statistical Computing, Vienna Austria) and significance is noted at α < 0.05 (p < 0.05).Results:Patients were treated between 14APR2020 and 09MAY2020. The peak of COVID 19 related deaths in New York was the 15th of April 2020. There have been 202 movements to the prone position and patients have received between 1 and 15 IPPs. There are 32 patients in the reported cohort and currently 12 patients are receiving IPP each day. Patients were 58.3± 1.7 years of age (37 to 73 years), 77% were male and had a BMI (body mass index) of 27.9 ± 0.7 (21 to 35). Pressor agents were being used in 74%, 16% were receiving dialysis, the white blood cell counts were 17.0 ± 1.5 (103/mcL) and their D dimers were 4630.0 ± 1588.0 ng/mL. At the time of consultation for prone positional therapy the patient’s arterial blood gas analyses were pH 7.28 ± 0.02, PaCO2 63.1 ± 3.53 mmHg, PaO2 of 80.5 ± 5.3 mmHg, HCO3 of 27.8 ± 1.0 mmol/L.The PFr prior to IPP was 108.0 ± 5.4and 1 hour after IPP was 152.8 ± 11.2 (p < 0.001). PFr after the patients were placed supine was 128.8 ± 9.2 (p = 0.014). Pre-prone PaCO2 was 59.7 ± 2.4 and the 1-hour post-prone PaCO2 was 68.9 ± 3.5 (p = 0.017 compared to pre-prone). The PaCO2measured supine one hour after IPP was 60.7 ± 3.3 (NS compared to pre-prone).The SaFr prior to IPP was 121.3 ± 4.2 and the SaFr 1 hour after positioning was 131.5 ± 5.1 (p = 0.012). The SaFr after the patients were placed supine was 139.7 ± 5.9 (p < 0.001 compared to pre-prone).Using regression coefficients, the SaF ratios predicted by PF ratios of 150 and 200 are 133.2 and 147.3, respectively.Conclusions:A program for prone positioning of adult patients with severe hypoxic ARDS due to COVID 19 can be designed and implemented rapidly, safely, and effectively during an overwhelming mass casualty scenario. This report describes one simple method that does not require any additional materials or labor from the already overburdened staff at the bedside. This approach may be equally applicable in both traditionally austere environments and in otherwise capable centers facing situational resource challenges.

Positional Obstructive Sleep Apnea Syndrome in Elderly Patients

Background The purpose of this study was to evaluate the prevalence of position-dependent obstructive sleep apnea (POSA) in elderly patients (≥65 years old). Adult (range 19-65 years old) and elderly patients were also compared in order to show differences in the incidence of POSA between these two groups of patients. Methods A prospective bi-center study was performed between January 2018 and May 2019. A total of 434 participants underwent polysomnography (PSG) study at home (Embletta MPR). Body position during the PSG recordings was determined. Patients were subdivided in two groups: those aged between 19 and 65 years old (adult patients) and ≥65 years old (elderly patients). POSA patients were defined using Cartwright’s system, Bignold classification, and the new Amsterdam Positional OSA Classification (APOC). Results The prevalence of POSA in elderly patients differed according to the classification system used: 49.3% using Cartwright’s classification system, 20.5% with the Bignold classification, and 22.6%, 38.9%, and 5.4% of APOC 1, APOC 2, and APOC3 sub-classes were respectively identified for the APOC classification system. No difference between adult and elderly patients regarding the prevalence of POSA was observed. No statistical differences emerged between the two groups of patients in terms of supine (p = 0.9) and non-supine AHI (p = 0.4). Conclusions A significant number of elderly patients could be considered treatable with positional therapy according to the APOC classification. However, the efficacy and applicability of positional therapy in elderly patients must be confirmed by further research.