Publications by authors named "Babak Mokhlesi"

160 Publications

Obesity and Obesity Hypoventilation, Sleep Hypoventilation, and Postoperative Respiratory Failure.

Anesth Analg 2021 May;132(5):1265-1273

Department of Medicine, University of Chicago, Chicago, Illinois.

Obesity hypoventilation syndrome (OHS) is considered as a diagnosis in obese patients (body mass index [BMI] ≥30 kg/m2) who also have sleep-disordered breathing and awake diurnal hypercapnia in the absence of other causes of hypoventilation. Patients with OHS have a higher burden of medical comorbidities as compared to those with obstructive sleep apnea (OSA). This places patients with OHS at higher risk for adverse postoperative events. Obese patients and those with OSA undergoing elective noncardiac surgery are not routinely screened for OHS. Screening for OHS would require additional preoperative evaluation of morbidly obese patients with severe OSA and suspicion of hypoventilation or resting hypoxemia. Cautious selection of the type of anesthesia, use of apneic oxygenation with high-flow nasal cannula during laryngoscopy, better monitoring in the postanesthesia care unit (PACU) can help minimize adverse perioperative events. Among other risk-reduction strategies are proper patient positioning, especially during intubation and extubation, multimodal analgesia, and cautious use of postoperative supplemental oxygen.
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http://dx.doi.org/10.1213/ANE.0000000000005352DOI Listing
May 2021

Identification of Sleep Medicine and Anesthesia Core Topics for Anesthesia Residency: A Modified Delphi Technique Survey.

Anesth Analg 2021 May;132(5):1223-1230

From the Department of Anesthesiology and Pain Medicine, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada.

Background: Sleep disorders affect up to 25% of the general population and are associated with increased risk of adverse perioperative events. The key sleep medicine topics that are most important for the practice of anesthesiology have not been well-defined. The objective of this study was to determine the high-priority sleep medicine topics that should be included in the education of anesthesia residents based on the insight of experts in the fields of anesthesia and sleep medicine.

Methods: We conducted a prospective cross-sectional survey of experts in the fields of sleep medicine and anesthesia based on the Delphi technique to establish consensus on the sleep medicine topics that should be incorporated into anesthesia residency curricula. Consensus for inclusion of a topic was defined as >80% of all experts selecting "agree" or "strongly agree" on a 5-point Likert scale. Responses to the survey questions were analyzed with descriptive statistical methods and presented as percentages or weighted mean values with standard deviations (SD) for Likert scale data.

Results: The topics that were found to have 100% agreement among experts were the influence of opioids and anesthetics on control of breathing and upper airway obstruction; potential interactions of wake-promoting/hypnotic medications with anesthetic agents; effects of sleep and anesthesia on upper airway patency; and anesthetic management of sleep apnea. Less than 80% agreement was found for topics on the anesthetic implications of other sleep disorders and future pathways in sleep medicine and anesthesia.

Conclusions: We identify key topics of sleep medicine that can be included in the future design of anesthesia residency training curricula.
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http://dx.doi.org/10.1213/ANE.0000000000005446DOI Listing
May 2021

Short sleep, sleep apnoea-associated hypoxaemic burden and kidney function: more questions than answers.

Thorax 2021 Mar 31. Epub 2021 Mar 31.

Medicine/Pulmonary and Critical Care, University of Chicago, Chicago, Illinois, USA

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http://dx.doi.org/10.1136/thoraxjnl-2020-216618DOI Listing
March 2021

Obstructive Sleep Apnea, Glucose Tolerance, and β-Cell Function in Adults With Prediabetes or Untreated Type 2 Diabetes in the Restoring Insulin Secretion (RISE) Study.

Diabetes Care 2021 Apr 5;44(4):993-1001. Epub 2021 Feb 5.

University of Chicago, Chicago, IL.

Objective: Obstructive sleep apnea (OSA) is associated with insulin resistance and has been described as a risk factor for type 2 diabetes. Whether OSA adversely impacts pancreatic islet β-cell function remains unclear. We aimed to investigate the association of OSA and short sleep duration with β-cell function in overweight/obese adults with prediabetes or recently diagnosed, treatment-naive type 2 diabetes.

Research Design And Methods: Two hundred twenty-one adults (57.5% men, age 54.5 ± 8.7 years, BMI 35.1 ± 5.5 kg/m) completed 1 week of wrist actigraphy and 1 night of polysomnography before undergoing a 3-h oral glucose tolerance test (OGTT) and a two-step hyperglycemic clamp. Associations of measures of OSA and actigraphy-derived sleep duration with HbA, OGTT-derived outcomes, and clamp-derived outcomes were evaluated with adjusted regression models.

Results: Mean ± SD objective sleep duration by actigraphy was 6.6 ± 1.0 h/night. OSA, defined as an apnea-hypopnea index (AHI) of five or more events per hour, was present in 89% of the participants (20% mild, 28% moderate, 41% severe). Higher AHI was associated with higher HbA ( = 0.007). However, OSA severity, measured either by AHI as a continuous variable or by categories of OSA severity, and sleep duration (continuous or <6 vs. ≥6 h) were not associated with fasting glucose, 2-h glucose, insulin sensitivity, or β-cell responses.

Conclusions: In this baseline cross-sectional analysis of the RISE clinical trial of adults with prediabetes or recently diagnosed, untreated type 2 diabetes, the prevalence of OSA was high. Although some measures of OSA severity were associated with HbA, OSA severity and sleep duration were not associated with measures of insulin sensitivity or β-cell responses.
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http://dx.doi.org/10.2337/dc20-2127DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7985427PMC
April 2021

Adherence to Positive Airway Pressure Therapy in Obesity Hypoventilation Syndrome.

Sleep Med Clin 2021 Mar 9;16(1):43-59. Epub 2020 Dec 9.

Sleep Disorders Center, University of Chicago, 5841 South Maryland Avenue, MC6076/Room M630, Chicago, IL 60637, USA. Electronic address:

Because of the prevalence of extreme obesity in the United States, there has been an increase in prevalence of obesity hypoventilation syndrome (OHS). There is limited information on the characteristics and pattern of positive airway pressure (PAP) adherence in patients with OHS compared with eucapnic patients with obstructive sleep apnea (OSA). This article discusses in detail the impact of PAP therapy on outcomes in patients with OHS, compares adherence between continuous PAP and noninvasive ventilation in OHS, and compares PAP adherence in patients with OHS to patients with moderate to severe OSA enrolled in clinical trials designed to improve CPAP adherence.
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http://dx.doi.org/10.1016/j.jsmc.2020.10.009DOI Listing
March 2021

CPAP titration failure is not equivalent to long-term CPAP treatment failure in patients with obesity hypoventilation syndrome: a case series.

J Clin Sleep Med 2020 11;16(11):1975-1981

Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, Illinois.

Study Objectives: Medium and long-term trials comparing continuous positive airway pressure (CPAP) with noninvasive ventilation in patients with obesity hypoventilation syndrome have shown no differences in outcomes. However, it remains unclear whether CPAP therapy should be prescribed if significant hypoxemia persists during CPAP titration, despite optimization of upper airway obstructive events or if maximum CPAP pressure is reached. We aimed to examine the effects of 6 weeks of home CPAP therapy on gas exchange in patients with obesity hypoventilation syndrome who failed CPAP titration due to persistent hypoxemia.

Methods: This case series is a substudy of a randomized-controlled trial evaluating efficacy of 3 different PAP modalities in obesity hypoventilation syndrome. Patients randomized to CPAP who failed titration and were prescribed CPAP are included. CPAP failure was defined as spending more than 20% of total sleep time with oxygen saturation below 90% despite adequate resolution of apneas and hypopneas. Follow-up data included in-laboratory polysomnogram on prescribed CPAP after 6 weeks of home CPAP therapy.

Results: Three of seven participants (43%) randomized to CPAP failed CPAP titration. All were morbidly obese, had severe OSA (apnea-hypopnea index > 90 events/h) and severe sleep hypoxemia (percentage of total sleep time with oxygen saturation < 90% [T90] = 60-89%). Hypoxemia (T90: 43-67%, T80: 0-31%, and T70: 0-11%) and hypercapnia (transcutaneous pressure of CO₂ levels > 50 mm Hg) persisted during CPAP titration polysomnogram. The final polysomnogram after 6 weeks of adherent home CPAP therapy showed effective control of obstructive sleep apnea. Hypoventilation and hypoxemia severity decreased significantly in all 3 participants.

Conclusions: Our data suggest that CPAP titration failure does not equal CPAP treatment failure.

Clinical Trial Registration: Registry: ClinicalTrials.gov; Name: AVAPS-AE Efficacy Study; URL: https://clinicaltrials.gov/ct2/show/NCT01368614; Identifier: NCT01368614.
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http://dx.doi.org/10.5664/jcsm.8712DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8034214PMC
November 2020

Risk of major cardiovascular and cerebrovascular complications after elective surgery in patients with sleep-disordered breathing: A retrospective cohort analysis.

Eur J Anaesthesiol 2020 Aug;37(8):688-695

From the Department of Anesthesia, Toronto Western Hospital, University Health Network (RC, CS, TM, JW, FC), Department of Anesthesia, University of Toronto (RC, CS, JW, FC), Centre for Sleep Health and Research, Toronto General Hospital, Toronto, Ontario, Canada (CMR) and Section of Pulmonary and Critical Care, Sleep Disorders Center, University of Chicago, Chicago, Illinois, USA (BM).

Background: There is limited and conflicting data on whether sleep-disordered breathing (SDB) is associated with postoperative major cardiovascular and cerebrovascular events (MACCE), and mortality.

Objectives: To determine whether SDB is associated with increased risks of MACCE, mortality and length of hospital stay.

Design: Retrospective cohort analysis from the Nationwide Inpatient Sample.

Setting: Adults who underwent elective abdominal, orthopaedic, prostatic, gynaecological, thoracic, transplant, vascular or cardiac surgery in the United States of America between 2011 and 2014.

Patients: The study cohort included 1813 974 surgical patients, of whom 185 615 (10.2%) had SDB. Emergency or urgent surgical procedures were excluded.

Main Outcome Measures: The incidences of MACCE, respiratory and vascular complications, in-hospital mortality and mean length of hospital stay were stratified by SDB. Linear and logistic regression models were constructed to determine the independent association between SDB and outcomes of interest.

Results: The incidences of MACCE [25.3 vs. 19.8%, odds ratio (OR) 1.20, P < 0.001] and respiratory complications (11.75 vs. 8.0%, OR 1.43, P < 0.001) were significantly higher in patients with SDB than in those without SDB. SDB was associated with higher rates of atrial fibrillation (14.7 vs. 10.8%, P < 0.001), other arrhythmias (6.0 vs. 5.4%, P < 0.001) and congestive heart failure (9.8 vs. 7.1%, P < 0.001). SDB patients had a lower rate of myocardial infarction (3.1 vs. 3.4%, OR 0.69, P < 0.001), lower mortality (0.6 vs. 1.3%, P < 0.001) and shorter length of hospital stay (4.8 vs. 5.2 days, P < 0.001).

Conclusion: SDB was associated with increased risks of MACCE, and respiratory and vascular complications, but had a lower incidence of in-hospital mortality and shorter length of hospital stay.
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http://dx.doi.org/10.1097/EJA.0000000000001267DOI Listing
August 2020

Can Long-term Treatment of Obstructive Sleep Apnea With CPAP Improve Glycemia and Prevent Type 2 Diabetes?

Diabetes Care 2020 08;43(8):1681-1683

Section of Pulmonary and Critical Care, Department of Medicine, and Sleep Disorders Center, The University of Chicago, Chicago, IL.

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http://dx.doi.org/10.2337/dci20-0014DOI Listing
August 2020

Sleep in hospitalized patients with chronic obstructive pulmonary disease: an observational study.

J Clin Sleep Med 2020 10;16(10):1693-1699

Section of General Internal Medicine, University of Chicago Medical Center, Chicago, Illinois.

Study Objectives: The aim of this study was to compare the risk of undiagnosed sleep disorders among medical patients with chronic obstructive pulmonary disease (COPD) compared with those without COPD.

Methods: In a prospective cohort study, hospitalized medical ward patients without a known sleep disorder were screened, using validated questionnaires, for sleep disorders, such as obstructive sleep apnea and insomnia. Daily sleep duration and efficiency in the hospital were measured via wrist actigraphy. Participants were classified into two groups: those with a primary or secondary diagnosis of COPD and those without a history of COPD diagnosis. Sleep outcomes were compared by COPD diagnosis.

Results: From March 2010 to July 2015, 572 patients completed questionnaires and underwent wrist actigraphy. On admission, patients with COPD had a greater adjusted risk of obstructive sleep apnea (adjusted odds ratio 1.82, 95% confidence interval 1.12-2.96, P = .015) and clinically significant insomnia (adjusted odds ratio 2.07, 95% confidence interval 1.12-3.83, P = .021); no differences were observed for sleep quality or excess sleepiness on admission. After adjustment, compared with patients without COPD, patients with COPD averaged 34 fewer minutes of nightly sleep (95% confidence interval 4.2-64.0 minutes, P = .026), as well as 22.5% lower odds of normal sleep efficiency while in the hospital (95% confidence interval 3.3%-37.9%, P = .024). No statistically significant differences were observed for in-hospital sleep quality, soundness, or ease of falling asleep.

Conclusions: Among hospitalized patients in medical wards, those with COPD have higher risk of OSA and insomnia and worse in-hospital sleep quality and quantity compared with those without COPD.
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http://dx.doi.org/10.5664/jcsm.8646DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7954007PMC
October 2020

Deep learning applied to polysomnography to predict blood pressure in obstructive sleep apnea and obesity hypoventilation: a proof-of-concept study.

J Clin Sleep Med 2020 10;16(10):1797-1803

Section of Pulmonary and Critical Care, Sleep Disorders Center, University of Chicago, Chicago, Illinois.

Study Objectives: Nocturnal blood pressure (BP) profile shows characteristic abnormalities in OSA, namely acute postapnea BP surges and nondipping BP. These abnormal BP profiles provide prognostic clues indicating increased cardiovascular disease risk. We developed a deep neural network model to perform computerized analysis of polysomnography data and predict nocturnal BP profile.

Methods: We analyzed concurrently performed polysomnography and noninvasive beat-to-beat BP measurement with a deep neural network model to predict nocturnal BP profiles from polysomnography data in 13 patients with severe OSA.

Results: A good correlation was noted between measured and predicted postapnea systolic and diastolic BP (Pearson r ≥ .75). Moreover, Bland-Altman analyses showed good agreement between the 2 values. Continuous systolic and diastolic BP prediction by the deep neural network model was also well correlated with measured BP values (Pearson r ≥ .83).

Conclusions: We developed a deep neural network model to predict nocturnal BP profile from clinical polysomnography signals and provide a potential prognostic tool in OSA. Validation of the model in larger samples and examination of its utility in predicting CVD risk in future studies is warranted.
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http://dx.doi.org/10.5664/jcsm.8608DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7954021PMC
October 2020

CPAP Adherence, Mortality, and Progression-Free Survival in Interstitial Lung Disease and OSA.

Chest 2020 Oct 22;158(4):1701-1712. Epub 2020 May 22.

Section of Pulmonary & Critical Care, Department of Medicine, The University of Chicago, Chicago, IL; Sleep Disorders Center, Department of Medicine, The University of Chicago, Chicago, IL.

Background: OSA, a common comorbidity in interstitial lung disease (ILD), could contribute to a worsened course if untreated. It is unclear if adherence to CPAP therapy improves outcomes.

Research Question: Does adherence to CPAP therapy improve outcomes in patients with concurrent interstitial lung disease and OSA?

Study Design And Methods: We conducted a 10-year retrospective observational multicenter cohort study, assessing adult patients with ILD who had undergone polysomnography. Subjects were categorized based on OSA severity into no/mild OSA (apnea-hypopnea index score < 15) or moderate/severe OSA (apnea-hypopnea index score ≥ 15). All subjects prescribed and adherent to CPAP were deemed to have treated OSA. Cox regression models were used to examine the association of OSA severity and CPAP adherence with all-cause mortality risk and progression-free survival (PFS).

Results: Of 160 subjects that met inclusion criteria, 131 had OSA and were prescribed CPAP. Sixty-six patients (41%) had no/mild untreated OSA, 51 (32%) had moderate/severe untreated OSA, and 43 (27%) had treated OSA. Subjects with no/mild untreated OSA did not differ from those with moderate/severe untreated OSA in mean survival time (127 ± 56 vs 138 ± 93 months, respectively; P = .61) and crude mortality rate (2.9 per 100 person-years vs 2.9 per 100 person-years, respectively; P = .60). Adherence to CPAP was not associated with improvement in all-cause mortality risk (hazard ratio [HR], 1.1; 95% CI, 0.4-2.9; P = .79) or PFS (HR, 0.9; 95% CI, 0.5-1.5; P = .66) compared with those that were nonadherent or untreated. Among subjects requiring supplemental oxygen, those adherent to CPAP had improved PFS (HR, 0.3; 95% CI, 0.1-0.9; P = .03) compared with nonadherent or untreated subjects.

Interpretation: Neither OSA severity nor adherence to CPAP was associated with improved outcomes in patients with ILD except those requiring supplemental oxygen.
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http://dx.doi.org/10.1016/j.chest.2020.04.067DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7545492PMC
October 2020

Long-term Noninvasive Ventilation in Obesity Hypoventilation Syndrome Without Severe OSA: The Pickwick Randomized Controlled Trial.

Chest 2020 Sep 25;158(3):1176-1186. Epub 2020 Apr 25.

Department of Medicine/Pulmonary and Critical Care, University of Chicago, IL.

Background: Noninvasive ventilation (NIV) is an effective form of treatment in obesity hypoventilation syndrome (OHS) with severe OSA. However, there is paucity of evidence in patients with OHS without severe OSA phenotype.

Research Question: Is NIV effective in OHS without severe OSA phenotype?

Study Design And Methods: In this multicenter, open-label parallel group clinical trial performed at 16 sites in Spain, we randomly assigned 98 stable ambulatory patients with untreated OHS and apnea-hypopnea index < 30 events/h (ie, no severe OSA) to NIV or lifestyle modification (control group) using simple randomization through an electronic database. The primary end point was hospitalization days per year. Secondary end points included other hospital resource utilization, incident cardiovascular events, mortality, respiratory functional tests, BP, quality of life, sleepiness, and other clinical symptoms. Both investigators and patients were aware of the treatment allocation; however, treating physicians from the routine care team were not aware of patients' enrollment in the clinical trial. The study was stopped early in its eighth year because of difficulty identifying patients with OHS without severe OSA. The analysis was performed according to intention-to-treat and per-protocol principles and by adherence subgroups.

Results: Forty-nine patients in the NIV group and 49 in the control group were randomized, and 48 patients in each group were analyzed. During a median follow-up of 4.98 years (interquartile range, 2.98-6.62), the mean hospitalization days per year ± SD was 2.60 ± 5.31 in the control group and 2.71 ± 4.52 in the NIV group (adjusted rate ratio, 1.07; 95% CI, 0.44-2.59; P = .882). NIV therapy, in contrast with the control group, produced significant longitudinal improvement in Paco, pH, bicarbonate, quality of life (Medical Outcome Survey Short Form 36 physical component), and daytime sleepiness. Moreover, per-protocol analysis showed a statistically significant difference for the time until the first ED visit favoring NIV. In the subgroup with high NIV adherence, the time until the first event of hospital admission, ED visit, and mortality was longer than in the low adherence subgroup. Adverse events were similar between arms.

Interpretation: In stable ambulatory patients with OHS without severe OSA, NIV and lifestyle modification had similar long-term hospitalization days per year. A more intensive program aimed at improving NIV adherence may lead to better outcomes. Larger studies are necessary to better determine the long-term benefit of NIV in this subgroup of OHS.

Trial Registry: ClinicalTrials.gov; No.: NCT01405976; URL: www.clinicaltrials.gov.
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http://dx.doi.org/10.1016/j.chest.2020.03.068DOI Listing
September 2020

Editorial: Metabolic Health in Normal and Abnormal Sleep.

Front Endocrinol (Lausanne) 2020 11;11:131. Epub 2020 Mar 11.

School of Medicine, Johns Hopkins University, Baltimore, MD, United States.

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http://dx.doi.org/10.3389/fendo.2020.00131DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7079282PMC
February 2021

Cost-effectiveness of positive airway pressure modalities in obesity hypoventilation syndrome with severe obstructive sleep apnoea.

Thorax 2020 06 26;75(6):459-467. Epub 2020 Mar 26.

Respiratory Department, San Pedro de Alcantara Hospital, Caceres, Spain.

Background: Obesity hypoventilation syndrome (OHS) is treated with either non-invasive ventilation (NIV) or CPAP, but there are no long-term cost-effectiveness studies comparing the two treatment modalities.

Objectives: We performed a large, multicentre, randomised, open-label controlled study to determine the comparative long-term cost and effectiveness of NIV versus CPAP in patients with OHS with severe obstructive sleep apnoea (OSA) using hospitalisation days as the primary outcome measure.

Methods: Hospital resource utilisation and within trial costs were evaluated against the difference in effectiveness based on the primary outcome (hospitalisation days/year, transformed and non-transformed in monetary term). Costs and effectiveness were estimated from a log-normal distribution using a Bayesian approach. A secondary analysis by adherence subgroups was performed.

Results: In total, 363 patients were selected, 215 were randomised and 202 were available for the analysis. The median (IQR) follow-up was 3.01 (2.91-3.14) years for NIV group and 3.00 (2.92-3.17) years for CPAP. The mean (SD) Bayesian estimated hospital days was 2.13 (0.73) for CPAP and 1.89 (0.78) for NIV. The mean (SD) Bayesian estimated cost per patient/year in the NIV arm, excluding hospitalisation costs, was €2075.98 (91.6), which was higher than the cost in the CPAP arm of €1219.06 (52.3); mean difference €857.6 (105.5). CPAP was more cost-effective than NIV (99.5% probability) because longer hospital stay in the CPAP arm was compensated for by its lower costs. Similar findings were observed in the high and low adherence subgroups.

Conclusion: CPAP is more cost-effective than NIV; therefore, CPAP should be the preferred treatment for patients with OHS with severe OSA.

Trial Registration Number: NCT01405976.
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http://dx.doi.org/10.1136/thoraxjnl-2019-213622DOI Listing
June 2020

The Effect of Hospital Discharge with Empiric Noninvasive Ventilation on Mortality in Hospitalized Patients with Obesity Hypoventilation Syndrome. An Individual Patient Data Meta-Analysis.

Ann Am Thorac Soc 2020 05;17(5):627-637

Department of Medicine, Boston University School of Medicine, Boston, Massachusetts; and.

Hospitalized patients with acute-on-chronic hypercapnic respiratory failure due to obesity hypoventilation syndrome (OHS) have increased short-term mortality. It is unknown whether prescribing empiric positive airway pressure (PAP) at the time of hospital discharge reduces mortality compared with waiting for an outpatient evaluation (i.e., outpatient sleep study and outpatient PAP titration). An international, multidisciplinary panel of experts developed clinical practice guidelines on OHS for the American Thoracic Society. The guideline panel asked whether hospitalized adult patients with acute-on-chronic hypercapnic respiratory failure suspected of having OHS, in whom the diagnosis has not yet been made, should be discharged from the hospital with or without empiric PAP treatment until the diagnosis of OHS is either confirmed or ruled out. A systematic review with individual patient data meta-analyses was performed to inform the guideline panel's recommendation. Grading of Recommendations, Assessment, Development, and Evaluation was used to summarize evidence and appraise quality. The literature search identified 2,994 articles. There were no randomized trials. Ten studies met study selection criteria, including two nonrandomized comparative studies and eight nonrandomized noncomparative studies. Individual patient data on hospitalized patients who survived to hospital discharge were obtained from nine of the studies and included a total of 1,162 patients (1,043 discharged with PAP and 119 discharged without PAP). Empiric noninvasive ventilation was prescribed in 91.5% of patients discharged on PAP, and the remainder received empiric continuous PAP. Discharge with PAP reduced mortality at 3 months (relative risk 0.12, 95% confidence interval 0.05-0.30, risk difference -14.5%). Certainty in the estimated effects was very low. Hospital discharge with PAP reduces mortality following acute-on-chronic hypercapnic respiratory failure in patients with OHS or suspected of having OHS. Well-designed clinical trials are needed to confirm this finding.
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http://dx.doi.org/10.1513/AnnalsATS.201912-887OCDOI Listing
May 2020

Weight Loss Interventions as Treatment of Obesity Hypoventilation Syndrome. A Systematic Review.

Ann Am Thorac Soc 2020 04;17(4):492-502

Department of Medicine, University of Chicago, Chicago, Illinois.

Obesity hypoventilation syndrome (OHS) is an undesirable consequence of obesity. Weight loss is an important component of management based on clinical rationale, but the evidence supporting weight loss has not been summarized and the optimal approach has not been determined. This systematic review informed an international, multidisciplinary panel of experts who had converged to develop a clinical practice guideline on OHS for the American Thoracic Society. The panel asked, "Should a weight loss intervention be performed in patients with OHS?" Medline, the Cochrane Library, and Embase were searched from January 1946 to March 2019 for studies that assessed weight loss interventions in obese adults with confirmed OHS, suspected OHS, or hypercapnia. The quality of the evidence was appraised using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach. The search identified 2,994 articles. Six studies were selected, including two randomized trials and four nonrandomized studies without a comparator. Sample size ranged from 16 to 63 subjects. The studies found that a comprehensive weight loss program (including motivational counseling, dieting, and exercise) can reduce weight by 6% to 7% but confers no clinically significant effects compared with standard care. Bariatric surgery, on the other hand, is associated with more robust weight loss (15-64.6%, depending on the type of intervention), reduction of obstructive sleep apnea severity (18-44% reduction of the apnea-hypopnea index), and improvement in gas exchange (17-20% reduction in partial pressure of carbon dioxide in the arterial blood), ultimately leading to the resolution of OHS. Moreover, daytime sleepiness and pulmonary artery pressure also improve with significant weight loss. Bariatric surgery is associated with adverse effects in roughly one-fifth of patients, but serious adverse effects are very rare. The level of certainty in the estimated effects was very low for most outcomes. The guideline panel for which the systematic review was performed made a conditional (i.e., weak) recommendation suggesting a weight loss intervention for patients with OHS, targeting a sustained weight loss of 25% to 30% of actual body weight. This recommendation was based on very low-quality evidence. Although the weight loss target is based on the observation that greater weight loss is associated with better outcomes, there is a need for better-quality studies to ascertain the degree of weight loss necessary to achieve improvement in clinically relevant outcomes in patients with OHS.
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http://dx.doi.org/10.1513/AnnalsATS.201907-554OCDOI Listing
April 2020

The Role of Positive Airway Pressure Therapy in Adults with Obesity Hypoventilation Syndrome. A Systematic Review and Meta-Analysis.

Ann Am Thorac Soc 2020 03;17(3):344-360

Department of Medicine, University of Chicago, Chicago, Illinois.

Obesity hypoventilation syndrome (OHS) is an undesirable complication of severe obesity. Although weight loss is an accepted component of management, it is difficult to achieve and sustain the degree of weight loss necessary to reverse OHS. As such, positive airway pressure (PAP) during sleep has become the cornerstone therapy for most patients with OHS. However, the value of PAP therapy remains uncertain. To perform a systematic review to determine whether adults with OHS should be treated with PAP therapy or not. This systematic review informed an international, multidisciplinary panel of experts who had converged to develop a clinical practice guideline on OHS for the American Thoracic Society. MEDLINE, the Cochrane Library, and Embase were searched from January 1946 to March 2019 for studies that compared PAP therapy (i.e., continuous PAP or noninvasive ventilation) to no PAP therapy in patients with OHS. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach was used to appraise the quality of evidence. The search identified 2,994 unique articles. The full text of 56 articles was reviewed, and 25 studies were selected, including 3 randomized trials, 12 nonrandomized comparative studies, and 10 randomized and nonrandomized studies without a comparator group. Sample size ranged from 21 to 1,527 patients. PAP was associated with increased resolution of OHS and improvements in mortality, gas exchange, daytime sleepiness, sleep quality, quality of life, and emergency department visits. Nearly half of patients experienced trivial adverse effects related to PAP therapy. Certainty in the estimated effects was low or very low for most outcomes. The panel made a conditional (i.e., weak) recommendation that PAP therapy during sleep be offered to patients with OHS to improve outcomes. This recommendation was based on very low-quality evidence.
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http://dx.doi.org/10.1513/AnnalsATS.201907-528OCDOI Listing
March 2020

Echocardiographic Changes with Positive Airway Pressure Therapy in Obesity Hypoventilation Syndrome. Long-Term Pickwick Randomized Controlled Clinical Trial.

Am J Respir Crit Care Med 2020 03;201(5):586-597

Respiratory Department, San Pedro de Alcántara Hospital, Cáceres, Spain.

Obesity hypoventilation syndrome (OHS) has been associated with cardiac dysfunction. However, randomized trials assessing the impact of long-term noninvasive ventilation (NIV) or continuous positive airway pressure (CPAP) on cardiac structure and function assessed by echocardiography are lacking. In a prespecified secondary analysis of the largest multicenter randomized controlled trial of OHS (Pickwick Project;  = 221 patients with OHS and coexistent severe obstructive sleep apnea), we compared the effectiveness of three years of NIV and CPAP on structural and functional echocardiographic changes. At baseline and annually during three sequential years, patients underwent transthoracic two-dimensional and Doppler echocardiography. Echocardiographers at each site were blinded to the treatment allocation. Statistical analysis was performed using a linear mixed-effects model with a treatment group and repeated measures interaction to determine the differential effect between CPAP and NIV. A total of 196 patients were analyzed: 102 were treated with CPAP and 94 were treated with NIV. Systolic pulmonary artery pressure decreased from 40.5 ± 1.47 mm Hg at baseline to 35.3 ± 1.33 mm Hg at three years with CPAP, and from 41.5 ± 1.56 mm Hg to 35.5 ± 1.42 with NIV ( < 0.0001 for longitudinal intragroup changes for both treatment arms). However, there were no significant differences between groups. NIV and CPAP therapies similarly improved left ventricular diastolic dysfunction and reduced left atrial diameter. Both NIV and CPAP improved respiratory function and dyspnea. In patients with OHS who have concomitant severe obstructive sleep apnea, long-term treatment with NIV and CPAP led to similar degrees of improvement in pulmonary hypertension and left ventricular diastolic dysfunction.Clinical trial registered with www.clinicaltrials.gov (NCT01405976).
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http://dx.doi.org/10.1164/rccm.201906-1122OCDOI Listing
March 2020

Clinical Practice Guideline Summary for Clinicians: Evaluation and Management of Obesity Hypoventilation Syndrome.

Ann Am Thorac Soc 2020 01;17(1):11-15

Division of Pulmonary and Critical Care, Department of Medicine, Mount Auburn Hospital, Cambridge, Massachusetts; and.

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http://dx.doi.org/10.1513/AnnalsATS.201908-579CMEDOI Listing
January 2020

The association of sleep disturbances with glycemia and obesity in youth at risk for or with recently diagnosed type 2 diabetes.

Pediatr Diabetes 2019 12 15;20(8):1056-1063. Epub 2019 Sep 15.

University of Chicago, Chicago, Illinois.

Objective: Poor sleep may increase obesity and type 2 diabetes (T2D) risk in youth. We explored whether subjective sleep duration, sleep quality, or risk for obstructive sleep apnea (OSA) are associated with glycemia, body mass index (BMI), or blood pressure (BP) in overweight/obese youth.

Methods: Two-hundred and fourteen overweight/obese youth of 10 to 19 years of age at risk for or recently diagnosed with T2D who were screened for the Restoring Insulin Secretion (RISE) Study had a 2-hour oral glucose tolerance test (OGTT) and completed a Cleveland Adolescent Sleepiness questionnaire and a Sleep Disturbances Scale questionnaire. Independent associations between sleep variables and measures of glycemia, BMI, and BP were evaluated with regression models.

Results: The multiethnic cohort was 67% female, 14.1 ± 2.1 years, and BMI 35.9 ± 6.5 kg/m . Habitual sleep duration <8 hours was reported in 74%. Daytime sleepiness was reported in 51%, poor sleep quality in 26%, and 30% had high obstructive sleep apnea (OSA) risk. Daytime sleepiness was associated with higher HbA1c (0.2%, P = .02) and 2-hour glucose (13.6 mg/dL, P < .05). Sleep duration, sleep quality, and OSA risk were not associated with the evaluated outcomes. Poor sleep quality and OSA risk were associated with higher BMI (2.9 kg/m , P = .004 and 2.83 kg/m , P < .003, respectively).

Conclusions: In overweight/obese youth with or at risk for T2D, daytime sleepiness was associated with higher HbA1c. In addition, poor sleep quality and OSA risk were associated with higher BMI. These findings support intervention studies aimed at improving sleep quality in obese youth.
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http://dx.doi.org/10.1111/pedi.12917DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7199716PMC
December 2019

Evaluation and Management of Obesity Hypoventilation Syndrome. An Official American Thoracic Society Clinical Practice Guideline.

Am J Respir Crit Care Med 2019 08;200(3):e6-e24

The purpose of this guideline is to optimize evaluation and management of patients with obesity hypoventilation syndrome (OHS). A multidisciplinary panel identified and prioritized five clinical questions. The panel performed systematic reviews of available studies (up to July 2018) and followed the Grading of Recommendations, Assessment, Development, and Evaluation evidence-to-decision framework to develop recommendations. All panel members discussed and approved the recommendations. After considering the overall very low quality of the evidence, the panel made five conditional recommendations. We suggest that: ) clinicians use a serum bicarbonate level <27 mmol/L to exclude the diagnosis of OHS in obese patients with sleep-disordered breathing when suspicion for OHS is not very high (<20%) but to measure arterial blood gases in patients strongly suspected of having OHS, ) stable ambulatory patients with OHS receive positive airway pressure (PAP), ) continuous positive airway pressure (CPAP) rather than noninvasive ventilation be offered as the first-line treatment to stable ambulatory patients with OHS and coexistent severe obstructive sleep apnea, ) patients hospitalized with respiratory failure and suspected of having OHS be discharged with noninvasive ventilation until they undergo outpatient diagnostic procedures and PAP titration in the sleep laboratory (ideally within 2-3 mo), and ) patients with OHS use weight-loss interventions that produce sustained weight loss of 25% to 30% of body weight to achieve resolution of OHS (which is more likely to be obtained with bariatric surgery). Clinicians may use these recommendations, on the basis of the best available evidence, to guide management and improve outcomes among patients with OHS.
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http://dx.doi.org/10.1164/rccm.201905-1071STDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6680300PMC
August 2019

Noninvasive Ventilation versus CPAP as Initial Treatment of Obesity Hypoventilation Syndrome.

Ann Am Thorac Soc 2019 10;16(10):1295-1303

Department of Medicine, University of Chicago, Chicago, Illinois.

Obesity hypoventilation syndrome (OHS) is an undesirable consequence of obesity. Treatment consists of weight loss and positive airway pressure (PAP) therapy. However, the preferred mode of PAP is uncertain. To perform a systematic review to determine whether PAP therapy should be initiated as noninvasive ventilation (NIV) or continuous PAP (CPAP) in ambulatory patients with OHS. This systematic review informed an international, multidisciplinary panel of experts who had converged to develop a clinical practice guideline on OHS for the American Thoracic Society. MEDLINE, the Cochrane Library, and Embase were searched from January 1946 to March 2019 for studies that compared initial treatment with NIV to CPAP in OHS. The Grading of Recommendations, Assessment, Development, and Evaluation approach was used to appraise the quality of evidence. The search identified 2,994 potentially relevant articles, the full text of 21 articles was reviewed, and five articles were selected. The five articles included three randomized trials (one reported as two articles) and an observational study. The sample size ranged from 36 to 225 subjects. The evidence showed no differences in mortality, cardiovascular events, and healthcare resource use between patients with OHS treated with NIV or CPAP. Both PAP modalities were similarly effective in improving gas exchange, the need for supplemental oxygen, daytime sleepiness, sleep quality, quality of life, dyspnea, and sleep-disordered breathing. There was also no significant difference in adherence to NIV or CPAP therapy. Certainty in the estimated effects was low or very low for some outcomes. Therefore, the conditional recommendation was based on very low-quality evidence. The panel made a conditional (i.e., weak) recommendation that CPAP rather than NIV be offered as the first-line treatment to stable ambulatory patients with OHS and coexistent severe obstructive sleep apnea (OSA). The effectiveness of CPAP is similar to that of NIV, but NIV is more costly and requires more resources than CPAP. Given that approximately 70% of patients with OHS have coexistent severe OSA, this recommendation applies to the great majority of patients with stable OHS, but it should not be extrapolated to patients with OHS without severe OSA. Patients of advanced age, with poor lung function, or with greater or recent acute ventilatory failure may not respond adequately to CPAP.
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http://dx.doi.org/10.1513/AnnalsATS.201905-380OCDOI Listing
October 2019

Sleep and activity patterns in older patients discharged from the hospital.

Sleep 2019 10;42(11)

Pritzker School of Medicine, University of Chicago, Chicago, IL.

Study Objectives: Although sleep disturbance is common in acutely ill patients during and after a hospitalization, how hospitalization affects sleep in general medicine patients has not been well characterized. We describe how sleep and activity patterns vary during and after hospitalization in a small population of older, predominately African American general medicine patients.

Methods: Patients wore a wrist accelerometer during hospitalization and post-discharge to provide objective measurements of sleep duration, efficiency, and physical activity. Random effects linear regression models clustered by subject were used to test associations between sleep and activity parameters across study days from hospitalization through post-discharge.

Results: We recorded 404 nights and 384 days from 54 patients. Neither nighttime sleep duration nor sleep efficiency increased from hospitalization through post-discharge (320.2 vs. 320.2 min, p = 0.99; 74.0% vs. 71.7%, p = 0.24). Daytime sleep duration also showed no significant change (26.3 vs. 25.8 min/day, p = 0.5). Daytime physical activity was significantly less in-hospital compared to post-discharge (128.6 vs. 173.2 counts/min, p < 0.01) and increased 23.3 counts/min (95% CI = 16.5 to 30.6, p < 0.01) per hospital day. A study day and post-discharge period interaction was observed demonstrating slowed recovery of activity post-discharge (β 3 = -20.8, 95% CI = -28.8 to -12.8, p < 0.01).

Conclusions: Nighttime sleep duration and efficiency and daytime sleep duration were similar in-hospital and post-discharge. Daytime physical activity, however, was greater post-discharge and increased more rapidly during hospitalization than post-discharge. Interventions, both in hospital and at home, to restore patient sleep and sustain activity improvements may improve patient recovery from illness.
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http://dx.doi.org/10.1093/sleep/zsz153DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6802567PMC
October 2019

Association of Habitual Daily Physical Activity With Glucose Tolerance and β-Cell Function in Adults With Impaired Glucose Tolerance or Recently Diagnosed Type 2 Diabetes From the Restoring Insulin Secretion (RISE) Study.

Diabetes Care 2019 08 8;42(8):1521-1529. Epub 2019 Jun 8.

University of Chicago, Chicago, IL.

Objective: We examined the relationship between habitual daily physical activity and measures of glucose tolerance, insulin sensitivity, and β-cell responses in adults with impaired glucose tolerance (IGT) or drug-naive, recently diagnosed type 2 diabetes.

Research Design And Methods: Participants included 230 adults (mean ± SD age 54.5 ± 8.5 years, BMI 35 ± 5.5 kg/m; 42.6% women) who underwent a 3-h oral glucose tolerance test (OGTT) and hyperglycemic clamp. Wrist accelerometers worn for 7 consecutive days measured total physical activity counts (TAC) (daily mean 233,460 [∼50th percentile for age]). We evaluated whether TAC was associated with fasting plasma glucose, OGTT 2-h plasma glucose or glucose incremental area under the curve (G-iAUC), hyperglycemic clamp measures of insulin sensitivity (steady-state glucose infusion rate/insulin [M/I]) and β-cell responses (acute C-peptide response to glucose, steady-state C-peptide, and maximal β-cell response), and OGTT C-peptide index (ΔC-peptide/Δglucose).

Results: After adjustments for confounders, there was no association of TAC with fasting plasma glucose, 2-h glucose, or G-iAUC. Higher TAC was associated with higher insulin sensitivity (M/I). After adjusting for M/I, higher TAC was not associated with measures of β-cell response.

Conclusions: In adults with IGT or drug-naive, recently diagnosed type 2 diabetes, higher levels of habitual physical activity are associated with higher insulin sensitivity. Further studies are needed to understand why higher levels of physical activity are not associated with better β-cell response.
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http://dx.doi.org/10.2337/dc19-0538DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6647043PMC
August 2019

Sympathetic neural responsiveness to sleep deprivation in older adults: sex differences.

Am J Physiol Heart Circ Physiol 2019 08 31;317(2):H315-H322. Epub 2019 May 31.

Department of Kinesiology and Integrative Physiology, Michigan Technological University, Houghton, Michigan.

Our laboratory has previously reported that total sleep deprivation (TSD) modifies muscle sympathetic neural activity (MSNA) differently in young men and women. Because postmenopausal women are among the highest risk for hypertension, this study compares MSNA responses with TSD in older men and women. We hypothesized that TSD would alter MSNA in older adults, with greater sympathoexcitation in postmenopausal women. Twenty-seven participants (14 men and 13 women) between the ages of 55 and 75 yr were tested twice, once after 24-h TSD and once after normal sleep (randomized, crossover design). Our primary outcome measure of MSNA (microneurography) was successful across both conditions in 20 participants (10 men and 10 women). Secondary outcome measures included seated blood pressure, heart rate, and fasting plasma testosterone, estradiol, and progesterone. Age (60 ± 1 vs. 61 ± 2 yr) and BMI (27 ± 1 vs. 26 ± 1 kg/m) were not different between groups. TSD increased systolic blood pressure in both men (124 ± 5 to 130 ± 4 mmHg) and women (107 ± 5 to 116 ± 4 mmHg), but the increases were not different between groups (condition, = 0.014; condition × sex, > 0.05). In contrast, TSD elicited divergent MSNA responses in older men and women. Specifically, MSNA burst frequency increased in postmenopausal women (28 ± 3 to 34 ± 3 burst/min), but not older men (38 ± 3 to 35 ± 3 bursts/min; condition × sex, = 0.032). In conclusion, TSD elicited sympathoexcitation in postmenopausal women but not age-matched men. These findings provide new mechanistic insight into reported links between sleep deprivation and hypertension. Epidemiological studies report that sleep deprivation is more strongly associated with hypertension in women than in men. In the present study, 24-h total sleep deprivation (TSD) increased blood pressure in postmenopausal women and age-matched men. In contrast, only women demonstrated increases in muscle sympathetic nerve activity after TSD. The sympathoexcitation observed in postmenopausal women suggests a potential contributing mechanism for epidemiological observations and advances our understanding of the complex relations between sleep, sex, and hypertension.
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http://dx.doi.org/10.1152/ajpheart.00232.2019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6732487PMC
August 2019

Association of Self-Reported Sleep and Circadian Measures With Glycemia in Adults With Prediabetes or Recently Diagnosed Untreated Type 2 Diabetes.

Diabetes Care 2019 07 2;42(7):1326-1332. Epub 2019 May 2.

University of Chicago, Chicago, IL.

Objective: Sleep disturbances and circadian misalignment (social jet lag, late chronotype, or shift work) have been associated with worse glycemic control in type 2 diabetes (T2D). Whether these findings apply to adults with prediabetes is yet unexplored. We hypothesized that self-reported short sleep, poor sleep quality, and/or circadian misalignment are associated with higher glycemia, BMI, and blood pressure (BP) in adults with prediabetes or recently diagnosed, untreated T2D.

Research Design And Methods: Our cohort included 962 overweight/obese adults ages 20-65 years with prediabetes or recently diagnosed, untreated T2D who completed a 2-h oral glucose tolerance test and validated sleep questionnaires. Independent associations of sleep and circadian variables with glycemia, BMI, and BP were evaluated with regression models.

Results: The multiethnic cohort was 55% men, with mean ± SD age 52.2 ± 9.5 years and BMI 34.7 ± 5.5 kg/m. Mean sleep duration was 6.6 ± 1.3 h. Poor sleep quality was reported by 54% and high risk for obstructive sleep apnea by 64%. HbA was significantly higher in those reporting <5 or >8 h sleep per night. Sleep duration >8 h was also associated with higher fasting glucose and <6 h with higher BMI. Shift work was also associated with higher BMI. Social jet lag and delayed chronotype were associated with higher BP.

Conclusions: In our cohort, self-reported short and long sleep were both associated with adverse measures of glycemia, and short sleep and shift work were associated with higher BMI. Further research using objective measures of sleep is needed to better delineate the relationship between sleep and glycemia in adults with prediabetes or T2D.
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http://dx.doi.org/10.2337/dc19-0298DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6609965PMC
July 2019

Long-term clinical effectiveness of continuous positive airway pressure therapy versus non-invasive ventilation therapy in patients with obesity hypoventilation syndrome: a multicentre, open-label, randomised controlled trial.

Lancet 2019 04 29;393(10182):1721-1732. Epub 2019 Mar 29.

Respiratory Department, San Pedro de Alcántara Hospital, Cáceres, Spain; CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain; Instituto Universitario de Investigación Biosanitaria de Extremadura (INUBE), Cáceres, Spain.

Background: Obesity hypoventilation syndrome is commonly treated with continuous positive airway pressure or non-invasive ventilation during sleep. Non-invasive ventilation is more complex and costly than continuous positive airway pressure but might be advantageous because it provides ventilatory support. To date there have been no long-term trials comparing these treatment modalities. We therefore aimed to determine the long-term comparative effectiveness of both treatment modalities.

Methods: We did a multicentre, open-label, randomised controlled trial at 16 clinical sites in Spain. We included patients aged 15-80 years with untreated obesity hypoventilation syndrome and an apnoea-hypopnoea index of 30 or more events per h. We randomly assigned patients, using simple randomisation through an electronic database, to receive treatment with either non-invasive ventilation or continuous positive airway pressure. Both investigators and patients were aware of the treatment allocation. The research team was not involved in deciding hospital treatment, duration of treatment in the hospital, and adjustment of medications, as well as adjudicating cardiovascular events or cause of mortality. Treating clinicians from the routine care team were not aware of the treatment allocation. The primary outcome was the number of hospitalisation days per year. The analysis was done according to the intention-to-treat principle. This study is registered with ClinicalTrials.gov, number NCT01405976.

Findings: From May 4, 2009, to March 25, 2013, 100 patients were randomly assigned to the non-invasive ventilation group and 115 to the continuous positive airway pressure group, of which 97 patients in the non-invasive ventilation group and 107 in the continuous positive airway pressure group were included in the analysis. The median follow-up was 5·44 years (IQR 4·45-6·37) for all patients, 5·37 years (4·36-6·32) in the continuous positive airway pressure group, and 5·55 years (4·53-6·50) in the non-invasive ventilation group. The mean hospitalisation days per patient-year were 1·63 (SD 3·74) in the continuous positive airway pressure group and 1·44 (3·07) in the non-invasive ventilation group (adjusted rate ratio 0·78, 95% CI 0·34-1·77; p=0·561). Adverse events were similar between both groups.

Interpretation: In stable patients with obesity hypoventilation syndrome and severe obstructive sleep apnoea, non-invasive ventilation and continuous positive airway pressure have similar long-term effectiveness. Given that continuous positive airway pressure has lower complexity and cost, continuous positive airway pressure might be the preferred first-line positive airway pressure treatment modality until more studies become available.

Funding: Instituto de Salud Carlos III, Spanish Respiratory Foundation, and Air Liquide Spain.
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http://dx.doi.org/10.1016/S0140-6736(18)32978-7DOI Listing
April 2019

Obesity hypoventilation syndrome.

Eur Respir Rev 2019 Mar 14;28(151). Epub 2019 Mar 14.

CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain.

Obesity hypoventilation syndrome (OHS) is defined as a combination of obesity (body mass index ≥30 kg·m), daytime hypercapnia (arterial carbon dioxide tension ≥45 mmHg) and sleep disordered breathing, after ruling out other disorders that may cause alveolar hypoventilation. OHS prevalence has been estimated to be ∼0.4% of the adult population. OHS is typically diagnosed during an episode of acute-on-chronic hypercapnic respiratory failure or when symptoms lead to pulmonary or sleep consultation in stable conditions. The diagnosis is firmly established after arterial blood gases and a sleep study. The presence of daytime hypercapnia is explained by several co-existing mechanisms such as obesity-related changes in the respiratory system, alterations in respiratory drive and breathing abnormalities during sleep. The most frequent comorbidities are metabolic and cardiovascular, mainly heart failure, coronary disease and pulmonary hypertension. Both continuous positive airway pressure (CPAP) and noninvasive ventilation (NIV) improve clinical symptoms, quality of life, gas exchange, and sleep disordered breathing. CPAP is considered the first-line treatment modality for OHS phenotype with concomitant severe obstructive sleep apnoea, whereas NIV is preferred in the minority of OHS patients with hypoventilation during sleep with no or milder forms of obstructive sleep apnoea (approximately <30% of OHS patients). Acute-on-chronic hypercapnic respiratory failure is habitually treated with NIV. Appropriate management of comorbidities including medications and rehabilitation programmes are key issues for improving prognosis.
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http://dx.doi.org/10.1183/16000617.0097-2018DOI Listing
March 2019

Effectiveness of SIESTA on Objective and Subjective Metrics of Nighttime Hospital Sleep Disruptors.

J Hosp Med 2019 01;14(1):38-41

University of Chicago Medicine, Chicago, Illinois, USA.

We created Sleep for Inpatients: Empowering Staff to Act (SIESTA), which combines electronic "nudges" to forgo nocturnal vitals and medications with interprofessional education on improving patient sleep. In one "SIESTAenhanced unit," nurses received coaching and integrated SIESTA into daily huddles; a standard unit did not. Six months pre- and post-SIESTA, sleep-friendly orders rose in both units (foregoing vital signs: SIESTA unit, 4% to 34%; standard, 3% to 22%, P < .001 both; sleeppromoting VTE prophylaxis: SIESTA, 15% to 42%; standard, 12% to 28%, P < .001 both). In the SIESTAenhanced unit, nighttime room entries dropped by 44% (-6.3 disruptions/room, P < .001), and patients were more likely to report no disruptions for nighttime vital signs (70% vs 41%, P = .05) or medications (84% vs 57%, P = .031) than those in the standard unit. The standard unit was not changed. Although sleep-friendly orders were adopted in both units, a unit-based nursing empowerment approach was associated with fewer nighttime room entries and improved patient experience.
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http://dx.doi.org/10.12788/jhm.3091DOI Listing
January 2019