Publications by authors named "Christopher J Lettieri"

58 Publications

Treatment of Obstructive Sleep Apnea: Achieving Adherence to Positive Airway Pressure Treatment and Dealing with Complications.

Sleep Med Clin 2020 Jun;15(2):227-240

Department of Psychiatry, University of Maryland School of Medicine, 100 North Greene Street, 2nd Floor, Baltimore, MD 21201, USA; Sleep Disorders Center, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, 100 North Greene Street, 2nd Floor, Baltimore, MD 21201, USA.

Obstructive sleep apnea is a common and treatable condition, but therapeutic adherence is limited by numerous factors. Despite advances in positive airway pressure (PAP) technology and a multitude of effective pharmacologic and behavioral therapeutic interventions to overcome the most common barriers to PAP, adherence has not increased significantly over the past 30 years. This review aims to identify the most important factors that impact adherence, common barriers to treatment, and evidence-based treatment strategies to maximize the effectiveness of PAP treatment. Complications of PAP treatment and mitigation techniques are also discussed.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jsmc.2020.02.009DOI Listing
June 2020

The Role of Weight Management in the Treatment of Adult Obstructive Sleep Apnea. An Official American Thoracic Society Clinical Practice Guideline.

Am J Respir Crit Care Med 2018 09;198(6):e70-e87

Background: Overweight/obesity is a common, reversible risk factor for obstructive sleep apnea severity (OSA). The purpose of this guideline is to provide evidence-based recommendations for the management of overweight/obesity in patients with OSA.

Methods: The Grading of Recommendations, Assessment, Development and Evaluation approach was used to evaluate the literature. Clinical recommendations were formulated by a panel of pulmonary, sleep medicine, weight management, and behavioral science specialists.

Results: Behavioral, pharmacological, and surgical treatments promote weight loss and can reduce OSA severity, reverse common comorbidities, and improve quality of life, although published studies have methodological limitations. After considering the quality of evidence, feasibility, and acceptability of these interventions, the panel made a strong recommendation that patients with OSA who are overweight or obese be treated with comprehensive lifestyle intervention consisting of 1) a reduced-calorie diet, 2) exercise or increased physical activity, and 3) behavioral guidance. Conditional recommendations were made regarding reduced-calorie diet and exercise/increased physical activity as separate management tools. Pharmacological therapy and bariatric surgery are appropriate for selected patients who require further assistance with weight loss.

Conclusions: Weight-loss interventions, especially comprehensive lifestyle interventions, are associated with improvements in OSA severity, cardiometabolic comorbidities, and quality of life. The American Thoracic Society recommends that clinicians regularly assess weight and incorporate weight management strategies that are tailored to individual patient preferences into the routine treatment of adult patients with OSA who are overweight or obese.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1164/rccm.201807-1326STDOI Listing
September 2018

Sleep, Sleep Disorders, and Circadian Health following Mild Traumatic Brain Injury in Adults: Review and Research Agenda.

J Neurotrauma 2018 11 24;35(22):2615-2631. Epub 2018 Aug 24.

11 Department of Neurosurgery, University of California , San Francisco, California.

A rapidly expanding scientific literature supports the frequent co-occurrence of sleep and circadian disturbances following mild traumatic brain injury (mTBI). Although many questions remain unanswered, the preponderance of evidence suggests that sleep and circadian disorders can result from mTBI. Among those with mTBI, sleep disturbances and clinical sleep and circadian disorders contribute to the morbidity and long-term sequelae across domains of functional outcomes and quality of life. Specifically, along with deterioration of neurocognitive performance, insufficient and disturbed sleep can precede, exacerbate, or perpetuate many of the other common sequelae of mTBI, including depression, post-traumatic stress disorder, and chronic pain. Further, sleep and mTBI share neurophysiologic and neuroanatomic mechanisms that likely bear directly on success of rehabilitation following mTBI. For these reasons, focus on disturbed sleep as a modifiable treatment target has high likelihood of improving outcomes in mTBI. Here, we review relevant literature and present a research agenda to 1) advance understanding of the reciprocal relationships between sleep and circadian factors and mTBI sequelae and 2) advance rapidly the development of sleep-related treatments in this population.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1089/neu.2017.5243DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6239093PMC
November 2018

More Than Just a Good Night's Sleep.

J Clin Sleep Med 2018 05 15;14(5):709-710. Epub 2018 May 15.

Directorate for Medicine, Fort Belvoir Community Hospital, Fort Belvoir, Virginia.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5664/jcsm.7084DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5940418PMC
May 2018

Ambulatory Surgery Has Minimal Impact on Sleep Parameters: A Prospective Observational Trial.

J Clin Sleep Med 2018 04 15;14(4):593-602. Epub 2018 Apr 15.

Department of Sleep Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland.

Study Objectives: The presence of obstructive sleep apnea (OSA) in ambulatory surgical patients causes significant perioperative concern; however, few data exist to guide clinicians' management decisions. The objective of this study was to measure changes in perioperative sleep parameters among an ambulatory surgery population.

Methods: This study is a prospective, observational study of ambulatory patients undergoing orthopedic surgery on an extremity. Study subjects completed three unattended home sleep apnea tests: baseline before surgery, the first night after surgery (N1), and third night after surgery (N3). Anesthesia and surgical teams were blinded to study participation and patients received routine perioperative care.

Results: Two hundred three subjects were enrolled and 166 completed the baseline home sleep test. Sixty-six (40.0%) had OSA at baseline, 35 patients received a new diagnosis, and 31 patients had a previous diagnosis of OSA. Of those with a previous diagnosis, 20 (64.5%) were compliant with continuous positive airway pressure therapy. Respiratory event index and SpO nadir did not significantly change postoperatively from baseline. Cumulative percentage of time oxygen saturation < 90% significantly increased N1 as compared to baseline for all patients except for those with moderate to severe OSA.

Conclusions: Ambulatory surgery had minimal effect on sleep parameters and there was no increase in adverse events among patients with either treated or untreated OSA.

Clinical Trial Registration: Registry: ClinicalTrials.gov; Title: Evaluation of Sleep Disordered Breathing Following Ambulatory Surgery; Identifier: NCT01851798; URL: https://clinicaltrials.gov/ct2/show/study/NCT01851798.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5664/jcsm.7052DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5886437PMC
April 2018

Doomed to Repeat History: The Burden of Trauma-Related Nightmares in Military Personnel.

J Clin Sleep Med 2018 03 15;14(3):303-305. Epub 2018 Mar 15.

Walter Reed National Military Medical Center, Bethesda, Maryland.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5664/jcsm.6964DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5837830PMC
March 2018

Treatment of Obstructive Sleep Apnea: Achieving Adherence to Positive Airway Pressure Treatment and Dealing with Complications.

Sleep Med Clin 2017 Dec 18;12(4):551-564. Epub 2017 Sep 18.

Department of Psychiatry, University of Maryland School of Medicine, 100 North Greene Street, 2nd Floor, Baltimore, MD 21201, USA; Sleep Disorders Center, Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Maryland School of Medicine, 100 North Greene Street, 2nd Floor, Baltimore, MD 21201, USA.

Obstructive sleep apnea is a common and treatable condition, but therapeutic adherence is limited by numerous factors. Despite advances in positive airway pressure (PAP) technology and a multitude of effective pharmacologic and behavioral therapeutic interventions to overcome the most common barriers to PAP, adherence has not increased significantly over the past 30 years. This review aims to identify the most important factors that impact adherence, common barriers to treatment, and evidence-based treatment strategies to maximize the effectiveness of PAP treatment. Complications of PAP treatment and mitigation techniques are also discussed.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jsmc.2017.07.005DOI Listing
December 2017

Impact of diagnosing and treating obstructive sleep apnea on healthcare utilization.

Sleep Med 2017 Oct 5;38:73-77. Epub 2017 Aug 5.

Pulmonary, Critical Care & Sleep Medicine, Walter Reed National Military Medical Center, Bethesda, MD, USA; Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.

Purpose: Obstructive sleep apnea (OSA) contributes to an increased risk for multiple co-morbidities and decreased quality of life. As a result, OSA patients may have higher usage of healthcare resources which can be mitigated with effective treatment. This study evaluates changes in healthcare utilization (HCU) following the initiation of therapy for OSA.

Methods: We conducted a retrospective study of newly diagnosed OSA patients. To assess total HCU, we incorporated the sum total of outpatient clinic encounters, laboratory tests, and medication prescriptions into a composite HCU score. Healthcare utilization for twelve months prior to positive airway pressure (PAP) was compared with twelve months after initiation of therapy. Reductions in HCU were correlated with PAP adherence.

Results: 650 consecutive patients were included. Mean age, gender, BMI, AHI, and ESS were 47.2 ± 8.8 years, 77.2% (men), 30.7 ± 4.9 kg/m, 37.1 ± 30.3, and 13.1 ± 5.1, respectively. Prior to PAP, mean outpatient visits, laboratory studies, medication prescriptions, and HCU composite score were 11.6 ± 10.4, 13.7 ± 11.0, 4.7 ± 3.2, and 29.7 ± 18.6, respectively. Following initiation of treatment, a 32.8% reduction in non-sleep outpatient visits was identified (p = 0.01) and a 16.4% decrease in laboratory studies (p = 0.02) was observed. There was a 19.9% reduction (p = 0.002) in HCU composite score. Those who were adherent with PAP had a 25.7% reduction in HCU composite score versus a 4.9% increase in those who discontinued PAP therapy (p < 0.001).

Conclusions: Diagnosing OSA and initiating PAP therapy resulted in a significant decrease in healthcare resource utilization. This reduction was greatest among those with higher baseline healthcare usage and those most adherent with therapy.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.sleep.2017.07.020DOI Listing
October 2017

The Continued Search for Optimal Therapy in Patients With OSA and PTSD.

J Clin Sleep Med 2017 06 15;13(6):849. Epub 2017 Jun 15.

Pulmonary, Critical Care and Sleep Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5664/jcsm.6644DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5443752PMC
June 2017

Challenges in the Management of Sleep Apnea and PTSD: Is the Low Arousal Threshold an Unrealized Target?

J Clin Sleep Med 2017 06 15;13(6):845-846. Epub 2017 Jun 15.

Pulmonary, Critical Care and Sleep Medicine, Walter Reed National Military Medical Center, Bethesda, Maryland.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5664/jcsm.6640DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5443750PMC
June 2017

The PTSD-OSA Paradox: They Are Commonly Associated and They Worsen Outcomes, but Treatment Nonadherence Is Common and the Therapeutic Effect Limited. What Are Clinicians To Do?

J Clin Sleep Med 2017 01 15;13(1):5-6. Epub 2017 Jan 15.

Pulmonary, Critical Care, and Sleep Medicine, Walter Reed National Military Medical Center, Bethesda, MD.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5664/jcsm.6370DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5181614PMC
January 2017

I-TRACH: Validating A Tool for Predicting Prolonged Mechanical Ventilation.

J Intensive Care Med 2018 Oct 30;33(10):567-573. Epub 2016 Nov 30.

1 Department of Pulmonary, Critical Care and Sleep Medicine, Walter Reed National Military Medical Center, Bethesda, MD, USA.

Purpose: We previously developed a bedside model (I-TRACH), which used commonly obtained data at the time of intubation to predict the duration of mechanical ventilation (MV). We now sought to validate this in a prospective trial.

Methods: A prospective, observational study of 225 consecutive adult medical intensive care unit patients requiring MV. Utilizing the original 6 variables used in the I-TRACH model (Intubation in the ICU, Tachycardia [heart rate > 110], Renal dysfunction [blood urea nitrogen > 25], Acidemia [pH < 7.25], Creatinine [>2.0 or >50% increase from baseline values], and decreased HCO [<20]), we (1) confirmed that these were still predictive of length of MV by multivariate analysis and (2) assessed the correlation between the number of criteria met and the subsequent duration of MV. In addition, we compared the performance of I-TRACH to Acute Physiology Age Chronic Health Evaluation-II and III, Sequential Organ Failure Assessment, and Acute Physiology Score as predictors of length of MV.

Results: Mean age was 62.6 ± 18.7 years, with a mean duration of MV of 5.8 ± 5.7 days. The number of I-TRACH criteria met directly correlated with the duration of MV. Individuals with ≥4 criteria were significantly more likely to require MV >7 and >14 days. Similarly, those who remained on ventilators for both >7 and >14 days met significantly more I-TRACH criteria than those requiring shorter durations of MV (1.7 ± 1.3 vs 2.8 ± 1.3 vs 3.8 ± 1.3 criteria, P < .001). I-TRACH performed better than all other models used to predict the duration of MV.

Conclusion: Similar to our previous retrospective study, these findings validate I-TRACH in determining the subsequent need for MV >7 and >14 days at the time of intubation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/0885066616679974DOI Listing
October 2018

Differences in sleep habits, study time, and academic performance between US-born and foreign-born college students.

Sleep Breath 2017 May 30;21(2):529-533. Epub 2016 Sep 30.

Department of Medicine, Uniformed Services of the Health Sciences, 4301 Jones Bridge Road, Bethesda, MD, 20814, USA.

Purpose: To inform the design of a sleep improvement program for college students, we assessed academic performance, sleep habits, study hours, and extracurricular time, hypothesizing that there would be differences between US-born and foreign-born students.

Methods: Questionnaires queried participants on bedtimes, wake times, nap frequency, differences in weekday and weekend sleep habits, study hours, grade point average, time spent at paid employment, and other extracurricular activities. Comparisons were made using chi square tests for categorical data and t tests for continuous data between US-born and foreign-born students.

Results: Of 120 participants (55 % women) with racial diversity (49 whites, 18 blacks, 26 Hispanics, 14 Asians, and 13 other), 49 (41 %) were foreign-born. Comparisons between US-born and foreign-born students showed no differences in average age or gender though US-born had more whites. There were no differences between US-born and foreign-born students for grade point averages, weekday bedtimes, wake times, or total sleep times. However, US-born students averaged 50 min less study time per day (p = 0.01), had almost 9 h less paid employment per week (14.5 vs 23.4 h per week, p = 0.001), and stayed up to socialize more frequently (63 vs 43 %, p = 0.03). Foreign-born students awakened an hour earlier and averaged 40 min less sleep per night on weekends.

Conclusions: Cultural differences among college students have a profound effect on sleep habits, study hours, and extracurricular time. The design of a sleep improvement program targeting a population with diverse cultural backgrounds must factor in such behavioral variations in order to have relevance and impact.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11325-016-1412-2DOI Listing
May 2017

Sleep, Sleep Disorders, and Mild Traumatic Brain Injury. What We Know and What We Need to Know: Findings from a National Working Group.

Neurotherapeutics 2016 Apr;13(2):403-17

Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA.

Disturbed sleep is one of the most common complaints following traumatic brain injury (TBI) and worsens morbidity and long-term sequelae. Further, sleep and TBI share neurophysiologic underpinnings with direct relevance to recovery from TBI. As such, disturbed sleep and clinical sleep disorders represent modifiable treatment targets to improve outcomes in TBI. This paper presents key findings from a national working group on sleep and TBI, with a specific focus on the testing and development of sleep-related therapeutic interventions for mild TBI (mTBI). First, mTBI and sleep physiology are briefly reviewed. Next, essential empirical and clinical questions and knowledge gaps are addressed. Finally, actionable recommendations are offered to guide active and efficient collaboration between academic, industry, and governmental stakeholders.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s13311-016-0429-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4824019PMC
April 2016

OSA Syndrome and Posttraumatic Stress Disorder: Clinical Outcomes and Impact of Positive Airway Pressure Therapy.

Chest 2016 Feb 1;149(2):483-490. Epub 2016 Jan 1.

Department of Medicine, Uniformed Services University, Bethesda, MD; Department of Pulmonary, Critical Care, and Sleep Medicine, Brooke Army Medical Center, Fort Sam Houston, TX. Electronic address:

Background: We sought to determine the impact of OSA syndrome (OSAS) on symptoms and quality of life (QoL) among patients with posttraumatic stress disorder (PTSD). In addition, we assessed adherence and response to positive airway pressure (PAP) therapy in this population.

Methods: This was a case-controlled observational cohort study at the Sleep Disorders Center of an academic military medical center. Two hundred consecutive patients with PTSD underwent sleep evaluations. Patients with PTSD with and without OSAS were compared with 50 consecutive age-matched patients with OSAS without PTSD and 50 age-matched normal control subjects. Polysomnographic data, sleep-related symptoms and QoL measures, and objective PAP usage were obtained.

Results: Among patients with PTSD, more than one-half (56.6%) received a diagnosis of OSAS. Patients with PTSD and OSAS had lower QoL and more somnolence compared with the other groups. Patients with PTSD demonstrated significantly lower adherence and response to PAP therapy. Resolution of sleepiness occurred in 82% of patients with OSAS alone, compared with 62.5% of PAP-adherent and 21.4% of nonadherent patients with PTSD and OSAS (P < .001). Similarly, posttreatment Functional Outcomes of Sleep Questionnaire ≥ 17.9 was achieved in 72% of patients with OSAS, compared with only 56.3% of patients with PTSD and OSA who were PAP adherent and 26.2% who were nonadherent (P < .03).

Conclusions: In patients with PTSD, comorbid OSAS is associated with worsened symptoms, QoL, and adherence and response to PAP. Given the negative impact on outcomes, the possibility of OSAS should be considered carefully in patients with PTSD. Close follow-up is needed to optimize PAP adherence and efficacy in this at-risk population.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1378/chest.15-0693DOI Listing
February 2016

Clinical Practice Guideline for the Treatment of Obstructive Sleep Apnea and Snoring with Oral Appliance Therapy: An Update for 2015.

J Clin Sleep Med 2015 Jul 15;11(7):773-827. Epub 2015 Jul 15.

University of Michigan, Ann Arbor, MI.

Introduction: Since the previous parameter and review paper publication on oral appliances (OAs) in 2006, the relevant scientific literature has grown considerably, particularly in relation to clinical outcomes. The purpose of this new guideline is to replace the previous and update recommendations for the use of OAs in the treatment of obstructive sleep apnea (OSA) and snoring.

Methods: The American Academy of Sleep Medicine (AASM) and American Academy of Dental Sleep Medicine (AADSM) commissioned a seven-member task force. A systematic review of the literature was performed and a modified Grading of Recommendations Assessment, Development, and Evaluation (GRADE) process was used to assess the quality of evidence. The task force developed recommendations and assigned strengths based on the quality of the evidence counterbalanced by an assessment of the relative benefit of the treatment versus the potential harms. The AASM and AADSM Board of Directors approved the final guideline recommendations.

Recommendations: 1. We recommend that sleep physicians prescribe oral appliances, rather than no therapy, for adult patients who request treatment of primary snoring (without obstructive sleep apnea). (STANDARD) 2. When oral appliance therapy is prescribed by a sleep physician for an adult patient with obstructive sleep apnea, we suggest that a qualified dentist use a custom, titratable appliance over non-custom oral devices. (GUIDELINE) 3. We recommend that sleep physicians consider prescription of oral appliances, rather than no treatment, for adult patients with obstructive sleep apnea who are intolerant of CPAP therapy or prefer alternate therapy. (STANDARD) 4. We suggest that qualified dentists provide oversight—rather than no follow-up—of oral appliance therapy in adult patients with obstructive sleep apnea, to survey for dental-related side effects or occlusal changes and reduce their incidence. (GUIDELINE) 5. We suggest that sleep physicians conduct follow-up sleep testing to improve or confirm treatment efficacy, rather than conduct follow-up without sleep testing, for patients fitted with oral appliances. (GUIDELINE) 6. We suggest that sleep physicians and qualified dentists instruct adult patients treated with oral appliances for obstructive sleep apnea to return for periodic office visits—as opposed to no follow-up—with a qualified dentist and a sleep physician. (GUIDELINE).

Conclusions: The AASM and AADSM expect these guidelines to have a positive impact on professional behavior, patient outcomes, and, possibly, health care costs. This guideline reflects the state of knowledge at the time of publication and will require updates if new evidence warrants significant changes to the current recommendations.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5664/jcsm.4858DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4481062PMC
July 2015

Postoperative CPAP use impacts long-term weight loss following bariatric surgery.

J Clin Sleep Med 2015 Mar 15;11(3):213-7. Epub 2015 Mar 15.

Department of Medicine, Uniformed Services University, Bethesda, MD.

Introduction: Obstructive sleep apnea (OSA) is common among bariatric surgery candidates. After surgical weight loss, OSA frequently persists and untreated OSA can lead to weight gain. Long-term continuous positive airway pressure (CPAP) adherence is unclear and poor adherence may worsen weight loss outcomes. We sought to determine the impact of CPAP use on long-term weight-loss outcomes in a cohort of bariatric patients.

Methods: Long-term observational study of bariatric surgery patients with OSA. Patients were evaluated with polysomnography preoperatively and one-year postoperatively. The cohort was again evaluated a mean of 7.2 years later to determine the relationship between long-term CPAP use and subsequent regain of weight.

Results: Twenty-four consecutive patients (aged 48.5 ± 9.4 years at time of surgery; 73% female) were included in the initial assessment, and long-term outcome data were available on 22 subjects. Persistent OSA was documented in 21 of 22 subjects (95%) one year postoperatively. Final evaluation occurred 7.2 ± 2.3 years following surgery. Weight (213.3 ± 39.1 to 235.3 ± 47.1 lb, p = 0.10) and BMI (32.5 ± 5.4 to 37.3 ± 8.2 kg/m(2), p = 0.03) increased in most (n = 19, 86.4%) from postoperative to final evaluation. CPAP use declined from 83.3% (preoperatively) to 38.1% (one year) and to 23.8% (final evaluation). BMI increased among those not using CPAP at long-term follow-up compared to those with continued CPAP use (6.8% v -1.8%, p = 0.05).

Conclusions: In our cohort of bariatric patients with OSA, long-term adherence to CPAP therapy was poor, and non-adherence was associated with weight gain. Ongoing follow-up of OSA in this population may help to preserve initial achievements after surgical weight loss.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5664/jcsm.4528DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4346641PMC
March 2015

The impact of sleep on soldier performance.

Curr Psychiatry Rep 2014 Aug;16(8):459

Pulmonary, Critical Care, and Sleep Medicine, Womack Army Medical Center, 2817 Reilly Rd, Fort Bragg, NC, USA,

The military population is particularly vulnerable to a multitude of sleep-related disorders owing to the type of work performed by active duty servicemembers (ADSMs). Inadequate sleep, due to insufficient quantity or quality, is increasingly recognized as a public health concern. Traditionally, ADSMs have been encouraged that they can adapt to insufficient sleep just as the body adapts to physical training, but there is a substantial body of scientific literature which argues that this is not possible. Additionally, the military work environment creates unique challenges with respect to treatment options for common sleep disorders like obstructive sleep apnea, restless legs syndrome, and parasomnias. This review highlights sleep disorders which are prevalent in the modern military force and discusses the impact of poor sleep on overall performance. Medical treatments and recommendations for unit leaders are also discussed.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11920-014-0459-7DOI Listing
August 2014

Sleep disorders in combat-related PTSD.

Sleep Breath 2015 Mar 22;19(1):175-82. Epub 2014 Apr 22.

Pulmonary, Critical Care, and Sleep Medicine, Womack Army Medical Center, Fort Bragg, NC, USA.

Purpose: We sought to assess the rate of sleep complaints and sleep disorders among active duty soldiers with deployment-related PTSD and to determine whether any clinical features differentiated those with sleep disorders.

Methods: Retrospective review of consecutive soldiers diagnosed with PTSD. We recorded subjective measures of sleep and polysomnographic data. We compared clinical and demographic variables including psychoactive medication use, psychiatric comorbidity, and combat-related traumatic injury with the presence of sleep disorders.

Results: One hundred thirty patients were included (91.5 % male, mean age of 35.1 ± 10.6 years, mean body mass index (BMI) 28.9 ± 4.4 Kg/m(2)). About 88.5 % had comorbid depression, with the majority (96.2 %) taking psychoactive medications (mean 3.4 ± 1.6 medications per patient). Over half of the cohort suffered combat-related traumatic physical injuries (54.6 %). The obstructive sleep apnea syndrome (OSAS) was diagnosed in 67.3 % (80 % of the cohort underwent polysomnography), with a mean apnea hypopnea index of 24.1 ± 22.8 events/hour and a mean oxygen saturation nadir of 84.2 ± 5.7 %. OSAS was significantly more common in the non-injured soldiers (72.9 vs. 38.0 %, p < 0.001). In multivariate analysis, absence of physical injury showed a trend towards predicting OSAS.

Conclusions: Sleep complaints are common among soldiers with PTSD. We observed significantly higher rates of OSAS among those without physical injuries, raising the possibility that underlying sleep-disordered breathing is a risk factor for the development of PTSD. This potential association requires further validation.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11325-014-0984-yDOI Listing
March 2015

Maximizing positive airway pressure adherence in adults: a common-sense approach.

Chest 2013 Aug;144(2):680-693

Departments of Medicine and Neurology, Emory University, Atlanta, GA.

Positive airway pressure (PAP) therapy is considered the most efficacious treatment of obstructive sleep apnea (OSA), especially moderate to severe OSA, and remains the most commonly prescribed. Yet suboptimal adherence presents a challenge to sleep-medicine clinicians. The purpose of the current review is to highlight the efficacy of published interventions to improve PAP adherence and to suggest a patient-centered clinical approach to enhancing PAP usage.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1378/chest.12-2681DOI Listing
August 2013

Impact of group education on continuous positive airway pressure adherence.

J Clin Sleep Med 2013 Jun 15;9(6):537-41. Epub 2013 Jun 15.

Pulmonary, Critical Care, and Sleep Medicine, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA.

Study Objectives: To compare the impact of a group educational program versus individual education on continuous positive airway pressure (CPAP) adherence.

Methods: Post hoc assessment of a performance improvement initiative designed to improve clinic efficiency, access to care, and time to initiate therapy. Consecutive patients newly diagnosed with obstructive sleep apnea (OSA) initiating CPAP therapy participated in either an individual or group educational program. The content and information was similar in both strategies.

Results: Of 2,116 included patients, 1,032 received education regarding OSA and CPAP through a group clinic, and 1,084 received individual education. Among the cohort, 76.6% were men, mean age 48.3 ± 9.2 years, mean body mass index 29.6 ± 4.6 kg/m(2), and mean apnea-hypopnea index was 33.3 ± 24.4 events/hour. Baseline characteristics were similar between groups. CPAP adherence was significantly greater in those participating in a group program than those receiving individual education. Specifically, CPAP was used for more nights (67.2% vs. 62.1%, p = 0.02) and more hours per night during nights used (4.3 ± 2.1 vs. 3.7 ± 2.8, p = 0.03). Further, fewer individuals discontinued therapy (10.6% vs. 14.5%, p < 0.001), more achieved regular use of CPAP (45.2%. vs. 40.6%, p = 0.08), and time to initiate therapy was shorter (13.2 ± 3.1 versus 24.6 ± 7.4 days, p < 0.001). Group education resulted in a 3- to 4-fold increase in the number of patients seen per unit time.

Conclusions: A group educational program facilitated improved CPAP adherence. If confirmed by prospective randomized studies, group CPAP education may be an appropriate alternative to individual counseling, may improve acceptance of and adherence to therapy, and decrease time to treatment.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5664/jcsm.2742DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3659372PMC
June 2013

Clinical model for predicting prolonged mechanical ventilation.

J Crit Care 2013 Oct 14;28(5):880.e1-7. Epub 2013 May 14.

Department of Medicine, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA. Electronic address:

Introduction: Mechanical ventilation (MV) predisposes patients to numerous complications, which increases with longer durations of treatment. Identifying individuals more likely to require prolonged MV (PMV) may alter ventilation strategies or potentially minimize the duration of therapy and its associated complications. Our aim was to identify clinical variables at the time of intubation that could identify individuals who will require PMV.

Methods: One hundred thirty consecutive adult patients requiring MV support in a medical intensive care unit (ICU)were retrospectively assessed. Prolonged MV was defined as MV support more than 14 days.

Results: Mean age was 62.3±21.1 years, 64.6% were men, and mean duration of MV support was 11.4±11.9 days. Prolonged MV was required in 31.3%. Requiring intubation after admission to the ICU, heart rate greater than 110, blood urea nitrogen more than 25 mg/dL, serum pH less than 7.25, serum creatinine more than 2.0 mg/dL, and a HCO3 less than 20 mEq/L were the only variables independently associated with PMV. Specificity for predicting PMV was 100% with 4 or more of these variables.

Conclusion: The novel predictive model, using Intubation in the ICU, Tachycardia, Renal dysfunction, Acidemia, elevated Creatinine, and a decreased HCO3, was highly specific in identifying patients who subsequently required PMV support and performed better than Acute Physiology Age Chronic Health Evaluation III.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jcrc.2013.03.013DOI Listing
October 2013

Bronchial arterial embolisation for massive haemoptysis in cavitary sarcoidosis.

BMJ Case Rep 2013 Jan 25;2013. Epub 2013 Jan 25.

Department of Internal Medicine, Walter Reed National Military Medical Center, Bethesda, MD, USA.

A 48-year-old non-smoking man with a 6-year history of pulmonary cavitary sarcoidosis presented with acute onset of haemoptysis of approximately 600 ml. Prior episodes of haemoptysis had resolved only after serial upper lobe wedge resections bilaterally and steroids. A chest CT identified bilateral upper lobe cavitary lesions with extravasation of contrast from a large right upper lobe cavity. The patient underwent urgent bronchial angiography and subsequent bronchial artery embolisation of a left bronchial artery and three right bronchial arteries. He was started on methotrexate and steroids for refractory sarcoidosis. Two years after embolisation, the patient remained haemoptysis-free with his sarcoid well controlled on methotrexate monotherapy.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/bcr-2012-008268DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3603832PMC
January 2013

The impact of posttraumatic stress disorder on CPAP adherence in patients with obstructive sleep apnea.

J Clin Sleep Med 2012 Dec 15;8(6):667-72. Epub 2012 Dec 15.

Pulmonary, Critical Care and Sleep Medicine, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA.

Introduction: Obstructive sleep apnea (OSA) is a common comorbid condition in patients with posttraumatic stress disorder (PTSD); insufficiently treated OSA may adversely impact outcomes. Sleep fragmentation and insomnia are common in PTSD and may impair CPAP adherence. We sought to determine the impact of combat-related PTSD on CPAP adherence in soldiers.

Methods: Retrospective case-control study. Objective measures of CPAP use were compared between OSA patients with and without PTSD. Groups were matched for age, BMI, and apnea-hypopnea index (AHI).

Results: We included 90 patients (45 Control, 45 PTSD). Among the cohort, mean age was 39.9 ± 11.2, mean BMI 27.9 ± 8.0, mean ESS 13.6 ± 5.7, and mean AHI 28.2 ± 22.4. There was a trend towards a higher rate of comorbid insomnia among patients with PTSD (25.8% vs. 11.1%, p = 0.10). PTSD was associated with significantly less use of CPAP. Specifically, CPAP was used on 61.4% ± 22.2% of nights in PTSD patients compared with 76.8% ± 16.4% in patients without PTSD (p = 0.001). Mean nightly use of CPAP was 3.4 ± 1.2 h in the PTSD group compared with 4.7 ± 2.2 h among controls (p < 0.001). Regular use of CPAP (> 4 h per night for > 70% of nights) was also lower among PTSD patients (25.2% vs. 58.3%, p = 0.01).

Conclusion: Among soldiers with OSA, comorbid PTSD was associated with significantly decreased CPAP adherence. Given the potential for adverse clinical outcomes, resolution of poor sleep quality should be prioritized in the treatment of PTSD and potential barriers to CPAP adherence should be overcome in patients with comorbid OSA.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5664/jcsm.2260DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3501663PMC
December 2012

Sleep disturbances among soldiers with combat-related traumatic brain injury.

Chest 2012 Sep;142(3):622-630

Department of Pulmonary, Critical Care, and Sleep Medicine, Walter Reed National Military Medical Center, Bethesda, MD; Department of Medicine, Uniformed Services University, Bethesda, MD.

Background: Sleep complaints are common among patients with traumatic brain injury. Evaluation of this population is confounded by polypharmacy and comorbid disease, with few studies addressing combat-related injuries. The aim of this study was to assess the prevalence of sleep disorders among soldiers who sustained combat-related traumatic brain injury.

Methods: The study design was a retrospective review of soldiers returning from combat with mild to moderate traumatic brain injury. All underwent comprehensive sleep evaluations. We determined the prevalence of sleep complaints and disorders in this population and assessed demographics, mechanism of injury, medication use, comorbid psychiatric disease, and polysomnographic findings to identify variables that correlated with the development of specific sleep disorders.

Results: Of 116 consecutive patients, 96.6% were men (mean age, 31.1 ± 9.8 years; mean BMI, 27.8 ± 4.1 kg/m²), and 29.5% and 70.5% sustained blunt and blast injuries, respectively. Nearly all (97.4%) reported sleep complaints. Hypersomnia and sleep fragmentation were reported in 85.2% and 54.3%, respectively. Obstructive sleep apnea syndrome (OSAS) was found in 34.5%, and 55.2% had insomnia. Patients with blast injuries developed more anxiety (50.6% vs 20.0%, P = .002) and insomnia (63% vs 40%, P = .02), whereas patients with blunt trauma had significantly more OSAS (54.3% vs 25.9%, P = .003). In multivariate analysis, blunt trauma was a significant predictor of OSAS (OR, 3.09; 95% CI, 1.02-9.38; P = .047).

Conclusions: Sleep disruption is common following traumatic brain injury, and the majority of patients develop a chronic sleep disorder. It appears that sleep disturbances may be influenced by the mechanism of injury in those with combat-related traumatic brain injury, with blunt injury potentially predicting the development of OSAS.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1378/chest.11-1603DOI Listing
September 2012

Comparison of adjustable and fixed oral appliances for the treatment of obstructive sleep apnea.

J Clin Sleep Med 2011 Oct;7(5):439-45

Pulmonary, Critical Care, and Sleep Medicine, Walter Reed Army Medical Center, Washington, DC 20307, USA.

Study Objectives: To compare the efficacy of adjustable and fixed oral appliances for the treatment of OSA.

Methods: Retrospective review of consecutive patients with OSA treated with either adjustable or fixed oral appliances. Polysomnography was conducted before and during therapy. Effective treatment was defined as an apnea-hypopnea index (AHI) < 5 events/h or < 10 events/h with resolution of sleepiness (Epworth < 10). We compared efficacy rates between fixed and adjustable appliances and sought to identify factors associated with greater success.

Results: We included 805 patients, 602 (74.8%) treated with an adjustable and 203 (25.2%) a fixed oral appliances. Among the cohort, 86.4% were men; mean age was 41.3 ± 9.2 years. Mean AHI was 30.7 ± 25.6, with 34.1% having mild (AHI 5-14.9), 29.2% moderate (AHI 15-29.9), and 36.8% severe (AHI ≥ 30) OSA. Successful therapy was significantly more common with adjustable appliances. Obstructive events were reduced to < 5/h in 56.8% with adjustable compared to 47.0% with fixed appliances (p = 0.02). Similarly, a reduction of events to < 10 with resolution of sleepiness occurred in 66.4% with adjustable appliances versus 44.9% with fixed appliances (p < 0.001). For both devices, success was more common in younger patients, with lower BMI and less severe disease.

Conclusions: Adjustable devices produced greater reductions in obstructive events and were more likely to provide successful therapy, especially in moderate-severe OSA. Fixed appliances were effective in mild disease, but were less successful in those with higher AHIs. Given these findings, the baseline AHI should be considered when selecting the type of oral appliance.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.5664/JCSM.1300DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3190841PMC
October 2011

Efficacy of an adjustable oral appliance and comparison with continuous positive airway pressure for the treatment of obstructive sleep apnea syndrome.

Chest 2011 Dec 2;140(6):1511-1516. Epub 2011 Jun 2.

Pulmonary and Critical Care Department, Madigan Army Medical Center, Tacoma, WA.

Background: We sought to establish the efficacy of an adjustable oral appliance (aOA) in the largest patient population studied to date, to our knowledge, and to provide a comparison with continuous positive airway pressure (CPAP).

Methods: We conducted a retrospective analysis of patients using an aOA. Results of overnight polysomnography with aOA titration were evaluated and compared with CPAP. Predictors of a successful aOA titration were determined using a multivariate logistic regression model.

Results: A total of 497 patients were given an aOA during the specified time period. The aOA reduced the mean apnea-hypopnea index (AHI) to 8.4 ± 11.4, and 70.3%, 47.6%, and 41.4% of patients with mild, moderate, and severe disease achieved an AHI < 5, respectively. Patients using an aOA decreased their mean Epworth Sleepiness Score by 2.71 (95% CI, 2.3-3.2; P < .001) at follow-up. CPAP improved the AHI by -3.43 (95% CI, 1.88-4.99; P < .001) when compared with an aOA, but when adjusted for severity of disease, this difference only reached significance for patients with severe disease (-5.88 [95% CI, -8.95 to -2.82; P < .001]). However, 70.1% of all patients achieved an AHI < 5 using CPAP compared with 51.6% for the aOA (P < .001). On multivariate analysis, baseline AHI was a significant predictor of achieving an AHI < 5 on aOA titration, and age showed a trend toward significance.

Conclusions: In comparison with past reports, more patients in our study achieved an AHI < 5 using an aOA. The aOA is comparable to CPAP for patients with mild disease, whereas CPAP is superior for patients with moderate to severe disease. A lower AHI was the only predictor of a successful aOA titration.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1378/chest.10-2851DOI Listing
December 2011

Does home sleep testing impair continuous positive airway pressure adherence in patients with obstructive sleep apnea?

Chest 2011 Apr 3;139(4):849-854. Epub 2011 Feb 3.

Department of Pulmonary, Critical Care, and Sleep Medicine, Walter Reed Army Medical Center, Washington DC.

Background: The increasing recognition of obstructive sleep apnea (OSA) and demand for polysomnography has created a need for home sleep testing (HST) using unattended diagnostic and titration studies. Although these studies increase access to care and reduce cost, the limited interaction with sleep laboratories may negatively affect positive airway pressure (PAP) adherence. We sought to determine the difference in PAP use between HST and traditional in-laboratory studies.

Methods: This observational cohort study included 210 patients with OSA classified into three equal groups. Following preestablished guidelines, group 1 underwent unattended, type III home diagnostic and unattended home auto-adjustable PAP (APAP) titrations; group 2 underwent in-laboratory, type I diagnostic and continuous PAP titration studies; group 3 underwent type I diagnostic and APAP titration studies. Group 1 was primarily managed and educated in a primary care clinic, whereas groups 2 and 3 received extensive education in an academic sleep medicine center. Objective measures of PAP use during the first 4 to 6 weeks of therapy were compared between groups.

Results: Type of study and location of care did not affect PAP adherence. PAP was used for 70%, 73%, and 72% of nights in groups 1, 2, and 3, respectively (P = .94). Mean hours of nightly use (4.4 ± 2.0 h, 4.7 ± 1.5 h, and 4.6 ± 1.5 h; P = .98) was also similar. Regular use was observed in 54%, 51%, and 50% of subjects (P = .84). Discontinuation rates were similar between groups.

Conclusions: PAP usage did not differ between those undergoing HST vs in-laboratory studies. HST offers a more accessible and cost-effective alternative without compromising therapeutic adherence.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1378/chest.10-1060DOI Listing
April 2011