Mortality prediction in chronic obstructive pulmonary disease and obstructive sleep apnea

BackgroundWe aimed to assess mortality in chronic obstructive pulmonary disease (COPD), obstructive sleep apnea (OSA), and overlap syndrome, and evaluate which polysomnographic indices—apnea-hypopnea index (AHI) or hypoxemic load measurements—better predict mortality within 10 years.MethodsAdults with symptoms suggestive of sleep apnea and airway disease who underwent both polysomnography and spirometry plus bronchodilator response tests between 2000 and 2018 were included and divided into four groups according to presence of COPD and moderate-to-severe OSA (AHI ≥15/h). We estimated mortality using a Cox model adjusted for demographic/anthropometric covariates and comorbidities; this was called clinical model. To evaluate prognostic performance, we compared the concordance index (C-index) between clinical model and extended models, which incorporated one of polysomnographic indices—AHI, sleep time spent with SpO₂ < 90% (TS90), and mean and lowest SpO₂.ResultsAmong 355 participants, patients with COPD alone (57/355, 16.1%) and COPD–OSA overlap syndrome (37/355, 10.4%) had increased all-cause mortality than those who had neither disease (152/355, 42.8%) (adjusted HR, 2.98 and 3.19, respectively). The C-indices of extended models with TS90 (%) and mean SpO₂ were significantly higher than that of clinical model (0.765 vs. 0.737 and 0.756 vs. 0.737, respectively; all P < 0.05); however, the C-index of extended model with AHI was not (0.739 vs. 0.737; P = 0.15).ConclusionsIn this cohort with symptoms of sleep apnea and airway disease, patients with overlap syndrome had increased mortality, but not higher than in those with COPD alone. The measurement of hypoxemic load, not AHI, better predicted mortality.     

序贯HFNC对中老年患者全麻胆囊切除术后低氧血症与再插管率的影响

目的探讨拔除气管插管后序贯经鼻高流量氧疗（HFNC）对中老年患者全麻胆囊切除术后低氧血症和再插管率的影响。 方法采用前瞻性随机对照研究，选取2019年1月至12月新疆维吾尔自治区第三人民医院重症医学科收治的全麻下行胆囊切除术患者90例，将其随机分为HFNC组（30例）、鼻导管组（30例）、面罩组（30例）。比较拔除气管插管前后各组间心率（HR）、血压和血气分析指标［动脉血氧分压（PaO₂）、动脉血二氧化碳分压（PaCO₂）、氧合指数］，以及拔管后患者不适感和再插管率情况。 结果拔除气管插管前，3组患者间HR、收缩压（SBP）、PaO₂、PaCO₂、氧合指数比较，差异无统计学意义（P＞0.05）。拔管后1 h，3组患者间HR和SBP比较，差异无统计学意义（P＞0.05）；HFNC组患者的PaO₂与氧合指数均高于面罩组，PaCO₂低于面罩组，差异均有统计学意义（P=0.013，P=0.009，P=0.031），但与鼻导管组比较，差异均无统计学意义（P=0.106，P=0.101，P=0.545）；面罩组与鼻导管组相比，PaO₂和氧合指数差异均无统计学意义（P=0.363，P=0.314）。鼻导管组黏膜干燥抱怨所占比例最高，面罩组的幽闭恐惧和恶心呕吐所占比例最高，差异均有统计学意义（P＜0.05）。3组患者再插管率比较，差异无统计学意义（P=0.484）。 结论对于中老年全麻下行胆囊切除术后低氧血症的患者而言，相比面罩氧疗，拔除气管插管后采用序贯HFNC可以更好地改善患者的PaO₂、PaCO₂、氧合指数和不适感，但不能降低再插管率。     

俯卧位肺复张对改善重症肺部感染低氧血症患者氧合指数肺内分流作用及对血流动力学的影响分析

目的:探讨俯卧位肺复张对改善重症肺部感染低氧血症患者氧合指数、肺内分流的作用及对血流动力学的影响。方法:选取本院2011年10月至2013年12月诊治的重症肺部感染低氧血症患者52例,采用随机数字表法分为两组,26例患者实施仰卧位肺复张为对照组,26例患者实施俯卧位肺复张为观察组,比较两组患者基础指标的改变情况、氧合指数与肺内分流状况、血流动力学指标的改变情况、不良反应情况。结果:治疗后,两组患者血氧饱和度、氧合指数均显著增加,而Qs/QT均显著降低。观察组患者血氧饱和度、氧合指数均明显高于对照组,观察组患者Qs/QT明显低于对照组,差异均有统计学意义(P<0.05)。肺复张时,两组患者中心静脉压、心脏排血指数、每博指数、全心舒张期末容积指数、全心射血分数均显著降低,而全身血管阻力均显著增加,差异均有统计学意义(P<0.05)。结论:俯卧位肺复张可明显改善重症肺部感染低氧血症患者的氧合指数,可有效减少肺内分流,对血流动力学的影响较轻,不良反应少且安全性高,值得临床推广使用。     

Sleep disorders are distinctively associated with exercise intolerance and sedentary behavior in children with cystic fibrosis

ObjectiveTo evaluate the presence of sleep disorders and its associations with exercise capacity and daily physical activity levels among children and adolescents with CF.MethodsChildren age 6–18 years with a diagnosis of CF were recruited. Information regarding sociodemographic profile, pulmonary function and nutritional status were collected. Sleep disorders (polysomnography), exercise capacity (modified shuttle test - MST) and daily physical activity levels (questionnaire and five days accelerometer use) were evaluated.ResultsThirty-one patients, median age of 9.6 years and forced expiratory volume in 1 s (FEV₁) of 68.1 ± 24.4%, were included. Obstructive sleep apnea syndrome (OSAS) was present in 32.3% and nocturnal hypoxemia in 29%. The MST distance correlated with the mean peripheral oxyhemoglobin saturation (SpO₂) during sleep (r = 0.40) and the percent of total sleep time with SpO₂<90% (r = −0.49). The final MST SpO₂ correlated with the occurrence of OSAS (r = −0.48) and mean nocturnal SpO₂ (r = 0.45). Sedentary activities, as measured by accelerometry, correlated with sleep architecture, including the percent of stage II (r = 0.60) and rapid eye movement (REM) stage sleep (r = −0.37). Patients with OSAS and nocturnal hypoxemia presented lower values (p < 0.05) of distance and final SpO₂ in the MST. Nocturnal hypoxemia was the main variable to influence exercise capacity (r² = 0.521).ConclusionSleep disorders are distinctively related with exercise capacity and daily physical activity levels, as nocturnal hypoxemia is associated with exercise intolerance and sleep architecture disorders are associated with sedentary physical activity levels.     

Persistent pulmonary hypertension of the newborn

Failure of the normal circulatory adaptation to extrauterine life results in persistent pulmonary hypertension of the newborn (PPHN). Although this condition is most often secondary to parenchymal lung disease or lung hypoplasia, it may also be idiopathic. PPHN is characterized by elevated pulmonary vascular resistance with resultant right-to-left shunting of blood and hypoxemia. Although the preliminary diagnosis of PPHN is often based on differential cyanosis and labile hypoxemia, the diagnosis is confirmed by echocardiography. Management strategies include optimal lung recruitment and use of surfactant in patients with parenchymal lung disease, maintaining optimal oxygenation and stable blood pressures, avoidance of respiratory and metabolic acidosis and alkalosis, and pulmonary vasodilator therapy. Extracorporeal membrane oxygenation is considered when medical management fails. Although mortality associated with PPHN has decreased significantly with improvements in medical care, there remains the potential risk for neurodevelopmental disability which warrants close follow-up of affected infants after discharge.     

围手术期低氧血症患者的无创呼吸支持治疗:欧洲麻醉学会与欧洲重症监护医学会联合指南解读

低氧血症是外科患者术后常见并发症,严重者可危及患者生命。氧疗是处理低氧血症患者最常用且有效的方法,鉴于常规氧疗(conventional oxygen therapy,COT)并不能有效预防低氧血症,故应提倡更有效的无创呼吸支持治疗以防治围手术期低氧血症,但相关规范并不完善。近期,欧洲麻醉学会(European Society of Anaesthesiology,ESA)与欧洲重症监护医学会(European Society of Intensive Care Medicine,ESICM)联合发布《围手术期低氧血症患者无创呼吸支持治疗的ESA/ESICM联合指南》,涵盖五大临床问题,并对COT、经鼻高流量氧疗(high flow nasal cannula,HFNC)、无创正压通气(noninvasive positive pressure ventilation,NIPPV)和持续气道正压(continuous positive airway pressure,CPAP)的有效性进行比较和推荐,共给出19条具体建议。该指南对指导临床正确选用无创呼吸支持治疗提供了重要依据,对有效治疗围手术期低氧血症具有重要意义。临床医师也应及早识别围手术期低氧血症的高危患者,术中积极实践肺保护性通气策略,以降低患者肺部并发症风险,从而预防围手术期低氧血症。