Seminars in respiratory and critical care medicine
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The burden of pleural diseases continues to rise and affects an increasingly complex and aging patient population. As such, thoracentesis is one of the most common procedures performed by respiratory physicians, as pleural fluid analysis can establish the diagnosis of pleural effusions in approximately 75% of the cases. ⋯ Medical thoracoscopy addresses some of the limitations of these techniques, allows a comprehensive pleural examination and targeted pleural biopsies, and offers the possibility of treatment of recurrence in the same setting. As such, medical thoracoscopy is ideally positioned as a valuable tool in the diagnosis of unexplained exudative pleural effusions.
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Semin Respir Crit Care Med · Oct 2014
ReviewSleep and sleep disordered breathing in hospitalized patients.
Sleep is a fundamental physiological process necessary for recovery from acute illness. Unfortunately for hospitalized patients, sleep is often short, fragmented, and poor in quality, and may be associated with adverse outcomes including inpatient delirium. ⋯ Mitigating the sequelae associated with poor sleep quality and sleep disordered breathing requires early identification of modifiable factors impacting a patient's sleep, including engagement of a multidisciplinary team. In this article, we review the current knowledge of sleep in hospitalized patients with a detailed focus on patients with sleep disordered breathing.
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Semin Respir Crit Care Med · Oct 2014
ReviewEnhancing adherence to positive airway pressure therapy for sleep disordered breathing.
Sleep disordered breathing is made up of a group of conditions that include obstructive sleep apnea, central sleep apnea, complex sleep apnea, and sleep-related hypoventilation. Continuous positive airway pressure (CPAP) is the first-line therapy for obstructive sleep apnea. The other forms of sleep disordered breathing require different types of positive airway pressure (PAP). ⋯ Addressing side effects such as nasal symptoms and equipment usability issues is also beneficial. Compliance can be monitored by the data download cards present in PAP machines, but clinicians must be aware of the limitations of the data obtained. The challenges of improving adherence occur along with the increasing need to demonstrate to payers a patient's adherence to and benefit from PAP therapy.
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Semin Respir Crit Care Med · Oct 2014
Review Comparative StudyHome sleep testing for the diagnosis of obstructive sleep apnea-indications and limitations.
The increasing prevalence and recognition of obstructive sleep apnea (OSA) coupled with an awareness of its detrimental health consequences has resulted in the need for timely and cost efficient access to diagnostic sleep testing and treatment. As a result, increased emphasis is being placed on simplified ambulatory models for the diagnosis and treatment of OSA using home sleep testing (HST). An ambulatory sleep program requires the combination of clinical assessment for identifying patients at high risk for OSA, HST for the diagnosis of OSA, and home auto-titrating positive airway pressure units for treatment. Randomized control trials evaluating the efficacy of this ambulatory approach to diagnose and treat OSA in high-risk patients without significant medical comorbidities reveal the potential for equivalent patient outcomes when compared with the use of polysomnography and in-laboratory continuous positive airway pressure titration.
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Semin Respir Crit Care Med · Oct 2014
ReviewAuto-adjusting and Advanced Positive Airway Pressure Therapeutic Modalities.
Continuous positive airway pressure (CPAP) therapy is the first-line treatment for obstructive sleep apnea (OSA). Although the gold standard for the treatment of OSA, CPAP may not be the optimal modality to treat more complex sleep disordered breathing such as Cheyne-Stokes respirations, opioid-induced central apnea, and complex sleep disordered breathing related to chronic hypoventilation syndromes (obesity-hypoventilation syndrome, restrictive thoracic disease due to neuromuscular or thoracic cage disease, chronic obstructive pulmonary disease). ⋯ Advanced positive airway pressure modalities have been developed in an effort to improve treatment of the more complex sleep disordered breathing syndromes including automated servo ventilation and volume-targeted pressure-limited ventilation. This article is intended to provide the clinician reader with a description of newer PAP modalities, a review of evidence-supported indications for use, as well as to provide a framework for managing patients with advanced positive airway pressure therapy.