Probable Change of Sleep Parameters after Resection and Reconstruction Surgeries in Patients with Oral Cavity or Oropharyngeal Cancers

In patients of oral cavity or oropharyngeal cancers, resection of the tumor and reconstruction of the defect may reduce the framework, add a bulky flap, alter the tissue flexibility, and contribute to postoperative obstructive sleep apnea (OSA). Postoperative OSA and the potential consequences may decrease the survival rate and reduce patients’ quality of life. It is unclear whether the surgery is associated with postoperative OSA. Here, we compared the polysomnographies (PSGs) before and after the surgery in 15 patients of oral cavity or oropharyngeal cancers (out of 68 patients of head and neck cancers) without a chemo- or radio-therapy. Each patient received the second PSG before the start of any indicated adjuvant therapy to prevent its interference. There were 14 men and 1 woman, with a mean age and a standard deviation (SD, same in the following) of 56.2 ± 12.8 years. There were 6 tongue cancers, 5 buccal cancers, 2 tonsil cancer, 1 lower gum cancer, and 1 trigone cancer. The results show that the surgery changed sleep parameters insignificantly in apnea-hypopnea index (AHI), mean oxyhemoglobin saturation of pulse oximetry (SpO2), minimum SpO2, mean desaturation, and desaturation index but increased mean heart rate in the patients with free flaps. These results hint that the effect of surgery on developing OSA was small in this sample, with a longer plate or a larger framework for a bulkier free flap. It needs future studies with a large sample size to generalize this first observation.

Oxygenation strategies during flexible bronchoscopy: a review of the literature

During flexible fiberoptic bronchoscopy (FOB) the arterial partial pressure of oxygen can drop, increasing the risk for respiratory failure. To avoid desaturation episodes during the procedure several oxygenation strategies have been proposed, including conventional oxygen therapy (COT), high flow nasal cannula (HFNC), continuous positive airway pressure (CPAP) and non-invasive ventilation (NIV). By a review of the current literature, we merely describe the clinical practice of oxygen therapies during FOB. We also conducted a pooled data analysis with respect to oxygenation outcomes, comparing HFNC with COT and NIV, separately. COT showed its benefits in patients undergoing FOB for broncho-alveolar lavage (BAL) or brushing for cytology, in those with peripheral arterial oxyhemoglobin saturation < 93% prior to the procedure or affected by obstructive disorder. HFNC is preferable over COT in patients with mild to moderate acute respiratory failure (ARF) undergoing FOB, by improving oxygen saturation and decreasing the episodes of desaturation. On the opposite, CPAP and NIV guarantee improved oxygenation outcomes as compared to HFNC, and they should be preferred in patients with more severe hypoxemic ARF during FOB.

Whole-genome association analyses of sleep-disordered breathing phenotypes in the NHLBI TOPMed program

Background Sleep-disordered breathing is a common disorder associated with significant morbidity. The genetic architecture of sleep-disordered breathing remains poorly understood. Through the NHLBI Trans-Omics for Precision Medicine (TOPMed) program, we performed the first whole-genome sequence analysis of sleep-disordered breathing. Methods The study sample was comprised of 7988 individuals of diverse ancestry. Common-variant and pathway analyses included an additional 13,257 individuals. We examined five complementary traits describing different aspects of sleep-disordered breathing: the apnea-hypopnea index, average oxyhemoglobin desaturation per event, average and minimum oxyhemoglobin saturation across the sleep episode, and the percentage of sleep with oxyhemoglobin saturation < 90%. We adjusted for age, sex, BMI, study, and family structure using MMSKAT and EMMAX mixed linear model approaches. Additional bioinformatics analyses were performed with MetaXcan, GIGSEA, and ReMap. Results We identified a multi-ethnic set-based rare-variant association (p = 3.48 × 10−8) on chromosome X with ARMCX3. Additional rare-variant associations include ARMCX3-AS1, MRPS33, and C16orf90. Novel common-variant loci were identified in the NRG1 and SLC45A2 regions, and previously associated loci in the IL18RAP and ATP2B4 regions were associated with novel phenotypes. Transcription factor binding site enrichment identified associations with genes implicated with respiratory and craniofacial traits. Additional analyses identified significantly associated pathways. Conclusions We have identified the first gene-based rare-variant associations with objectively measured sleep-disordered breathing traits. Our results increase the understanding of the genetic architecture of sleep-disordered breathing and highlight associations in genes that modulate lung development, inflammation, respiratory rhythmogenesis, and HIF1A-mediated hypoxic response.

Severity of Central Sleep Apnea Does Not Affect Sleeping Oxygen Saturation During Ascent to High Altitude

Central sleep apnea (CSA) is characterized by periodic breathing (PB) during sleep, defined as intermittent periods of apnea/hypopnea and hyperventilation, with associated acute fluctuations in oxyhemoglobin saturation (SO2). CSA has an incidence of ~50% in heart failure patients but is universal at high-altitude (HA; ≥2,500 m), increasing in severity with further ascent and/or time at altitude. However, whether PB is adaptive, maladaptive, or neutral with respect to sleeping SO2 at altitude is unclear. We hypothesized that PB severity would improve mean sleeping SO2 during acclimatization to HA due to relative, intermittent hyperventilation subsequent to each apnea. We utilized portable sleep monitors to assess the incidence and severity of CSA via apnea-hypopnea index (AHI) and oxygen desaturation index (ODI), and peripheral oxygen saturation (SpO2) during sleep during two ascent profiles to HA in native lowlanders: (I) rapid ascent to and residence at 3,800 m for 9 days/nights (n=21) and (II) incremental ascent to 5,160 m over 10 days/nights (n=21). In both ascent models, severity of AHI and ODI increased and mean sleeping SpO2 decreased, as expected. However, during sleep on the last night/highest altitude of both ascent profiles, neither AHI nor ODI were correlated with mean sleeping SpO2. In addition, mean sleeping SpO2 was not significantly different between high and low CSA. These data suggest that CSA is neither adaptive nor maladaptive with regard to mean oxygen saturation during sleep, owing to the relative hyperventilation between apneas, likely correcting transient apnea-mediated oxygen desaturation and maintaining mean oxygenation.

Clinical characteristics of coronavirus disease 2019 (COVID-19) in patients out of Wuhan from China: a case control study

Background A large-scale global outbreak of coronavirus disease-19 (COVID-19) out of Wuhan, from China, occurred in January 2020. To examine the clinical characteristics of COVID-19 in infected patients out of Wuhan, from China. Methods Thirteen patients were confirmed to be infected with novel coronavirus-2019 (2019-nCoV) between January 27 and February 8, 2020, in Baoji city, Shannxi, northwestern China. Epidemiological and clinical information, and computed to morphology imaging data from all COVID-19 patients were collected; cases were divided into two groups according to the severity of infection (mild or severe). Results Nine (9/13) COVID-19 patients exhibited mild disease severity, and defined as second-generation human-to-human transmission cases. Most patients (11/13) had a history of travel to or from Wuhan. There were no differences in sex and age between the mild and severe cases (all P > 0.05). A moderate degree of fever (11/13), cough (13/13), and fatigue (8/13) were common symptoms; however, there was no statistical difference between mild and severe cases in this regard (all P > 0.05). Oxyhemoglobin saturation and oxygenation index decreased, and C-reactive protein (CRP) and serum amyloid A (SAA) levels were elevated in all patients with COVID-19 infection, with statistically significant differences between those with severe disease and mild infection (all P < 0.05). Twelve of 13 COVID-19 patients exhibited changes in chest CT imaging features, and time course changes were different between mild and severe cases (all P < 0.05). Conclusion Most cases of COVID-19 infection were second-generation human-to-human transmissions from Wuhan and were mild in severity. The clinical characteristics of COVID-19 varied. Oxyhemoglobin saturation, oxygenation index, CRP and SAA levels, and CT features were reliable parameters to evaluate the severity of COVID-19 infection. However, a few patients with mild COVID-19 disease lacked typical characteristics such as fever and changes in CT imaging features.

Emergency Sugammadex Reversal in an 850-G Premature Infant: A Case Report

Sugammadex is a novel reversal agent for the neuromuscular blocking agents rocuronium and vecuronium; it has been shown to rapidly and completely reverse neuromuscular blockade for rocuronium and vecuronium, even when the blockade is profound. We present the case of a 2-week-old, 850-g infant born at 25 weeks' gestation, who presented to the operating room for exploratory laparotomy and repair of ileal atresia. Anesthesia was induced and neuromuscular blockade with 1.2 mg/kg of rocuronium was administered. The neonate experienced rapid oxyhemoglobin desaturation and progressively became very difficult to mask ventilate. Direct laryngoscopy failed to result in successful intubation of the trachea and ventilation became impossible. To reverse the effects of rocuronium, 16 mg/kg of sugammadex was administered. Immediately after, the infant resumed spontaneous ventilation and was able to maintain adequate oxyhemoglobin saturation between 90% and 95% with supplemental oxygen. To our knowledge, this is the first report of successful reversal of neuromuscular blockade, with sugammadex, in an emergent situation after failure to intubate/ventilate an extremely low birth weight infant.

Effect of training on the development of exercise-induced arterial hypoxemia in volleyball players

Background and Study Aim. The purpose of this study was to examine the effect of volleyball training on the development of exercise-induced arterial hypoxemia during incremental exercise in male competitive volleyball players. Material and Methods. Eight male amateur volleyball players (age 21±1.3 years) participated in a 6-week volleyball training program three times a week in the pre-season preparatory period. Before and after the training period, all players performed an incremental treadmill test to determine maximal oxygen uptake (VO2max), and oxyhemoglobin saturation (SaO2) was continuously measured using a pulse oximeter during the test. Maximal values of minute ventilation (VEmax), respiratory exchange ratio (RERmax), ventilatory equivalent for oxygen (VE/VO2) and carbon dioxide (VE/VCO2) were determined. Exercise-induced arterial hypoxemia (EIAH) was defined as a SaO2 decreased by at least 4% (ΔSaO2≤ −4%) from resting level. Results. All the players exhibited exercise-induced arterial hypoxemia before (ΔSaO2= –8.8±3.3%) and after (ΔSaO2= –8.31.5%) the training period. SaO2 was significantly decreased from 97.6±1% at rest to 88.7±2.7% at exhaustion before the training period, and from 97.2±1.1% at rest to 88.8±2.1% at exhaustion after training period (p < 0.001). There was no significant difference in resting and lowest SaO2 values by comparison between the before and after training (p > 0.05). There were no significant changes in VO2max, VEmax, RERmax, VE/VO2 and VE/VCO2 after training period (p > 0.05). Conclusions. The results of this study showed that volleyball players with a history of anaerobic training may exhibit EIAH, but that 6-week volleyball training has no effect on the degree of exercise-induced arterial hypoxemia.

Increasing Hypopnea in Sleep Breathing Disturbance Improves Postoperative Oxygen Saturation in Patients with Very Severe Obstructive Sleep Apnea

In patients of very severe obstructive sleep apnea (OSA) with confined framework, reducing volume is difficult to achieve a postoperative apnea-hypopnea index (AHI) qualifying the classical surgical success. However, a higher AHI with a larger part of hypopneas may have similar or even less severity of oxygen (O2) desaturation, compared to a lower index mostly made of apneas. Here, in 27 consecutive enrolled patients, we show that besides the improvement of mean AHI, the multilevel surgery increased hypopnea in AHI from 29.1% to 77.3%, and improves postoperative O2 saturation by reducing desaturation frequency (mean desaturation index decreased from 62.5 to 24.4 events/h) and level (mean oxyhemoglobin saturation of pulse oximetry (SpO2) desaturation cut down from 10.0 to 5.8%). The mean SpO2 improved from 92.3% to 94.7%, and the improvement was positively related to the proportion increase of hypopnea/AHI. The results suggest that the non-framework surgery could help patients with very severe OSA whose AHIs are ≥60 events/h in terms of improving postoperative O2 saturation. Due to the improvement also presented in those not qualified as classical surgical success, further studies are needed to clarify the connection between O2 desaturation and various consequences to reconsider defining a surgical success.

Validation of Fabric-Based Thigh-Wearable EMG Sensors and Oximetry for Monitoring Quadriceps Activity during Strength and Endurance Exercises

Muscle oximetry based on near-infrared spectroscopy (NIRS) and electromyography (EMG) techniques in adherent clothing might be used to monitor the muscular activity of selected muscle groups while exercising. The fusion of these wearable technologies in sporting garments can allow the objective assessment of the quality and the quantity of the muscle activity as well as the continuous monitoring of exercise programs. Several prototypes integrating EMG and NIRS have been developed previously; however, most devices presented the limitations of not measuring regional muscle oxyhemoglobin saturation and did not embed textile sensors for EMG. The purpose of this study was to compare regional muscle oxyhemoglobin saturation and surface EMG data, measured under resting and dynamic conditions (treadmill run and strength exercises) by a recently developed wearable integrated quadriceps muscle oximetry/EMG system adopting smart textiles for EMG, with those obtained by using two “gold standard” commercial instrumentations for EMG and muscle oximetry. The validity and agreement between the wearable integrated muscle oximetry/EMG system and the “gold standard” instrumentations were assessed by using the Bland-Altman agreement plots to determine the bias. The results support the validity of the data provided by the wearable electronic garment developed purposely for the quadriceps muscle group and suggest the potential of using such device to measure strength and endurance exercises in vivo in various populations.

Effectiveness of convalescent plasma therapy in severe COVID-19 patients

Currently, there are no approved specific antiviral agents for novel coronavirus disease 2019 (COVID-19). In this study, 10 severe patients confirmed by real-time viral RNA test were enrolled prospectively. One dose of 200 mL of convalescent plasma (CP) derived from recently recovered donors with the neutralizing antibody titers above 1:640 was transfused to the patients as an addition to maximal supportive care and antiviral agents. The primary endpoint was the safety of CP transfusion. The second endpoints were the improvement of clinical symptoms and laboratory parameters within 3 d after CP transfusion. The median time from onset of illness to CP transfusion was 16.5 d. After CP transfusion, the level of neutralizing antibody increased rapidly up to 1:640 in five cases, while that of the other four cases maintained at a high level (1:640). The clinical symptoms were significantly improved along with increase of oxyhemoglobin saturation within 3 d. Several parameters tended to improve as compared to pretransfusion, including increased lymphocyte counts (0.65 × 109/L vs. 0.76 × 109/L) and decreased C-reactive protein (55.98 mg/L vs. 18.13 mg/L). Radiological examinations showed varying degrees of absorption of lung lesions within 7 d. The viral load was undetectable after transfusion in seven patients who had previous viremia. No severe adverse effects were observed. This study showed CP therapy was well tolerated and could potentially improve the clinical outcomes through neutralizing viremia in severe COVID-19 cases. The optimal dose and time point, as well as the clinical benefit of CP therapy, needs further investigation in larger well-controlled trials.