The rare cause of Severe Pulmonary Hypertension (free full text from 2017 Moldovan Journal of Health Sciences)

Female patient, aged 57, retired, non-smoking, presents dyspnea on exertion, at minimal effort, chronic severe fatigue, daytime sleepiness, insomnia, broken sleep associated with snoring and apneas, nocturia (2-3 times/night), morning headaches and xerostomia, periodic pain in the periumbilical region. 

From history: juvenile obesity (100 kg), hypertensive since the age of 50, presents sleep disturbances and noisy snoring for over 10 years. The physical examination reveals dry skin, mild inferior limbs edema, acrocyanosis (lips, legs), obesity with the BMI = 47 kg/m2 (m=118 kg, h=154 cm), neck girth = 43 cm, abdominal circumference = 140 cm, umbilical hernia 3x4 cm, free nasal breathing, diminished vesicular sounds, stable hemodynamics (HR= 68/min; BP= 130/80 mmHg), Mallampati score III and17 points on the Epworth Sleepiness Scale.

Chest X-ray was normal, ECG revealed signs of right ventricular strain. The EcoCG revealed slight dilation of both atria (up to 56 mm) with the left ventricle of normal dimensions and preserved ejection fraction (50%), severe right ventricle (RV) dilatation (46 mm) and severe pulmonary hypertension (pulmonary artery systolic pressure 80 mm Hg). SpO2 at rest is 95%. Spirometric and blood gazes values are as follows FEV1-81%; FVC-80%; FEV1/FVC-109%, pH 7,43; PaO₂ 96 mm Hg; PaCO₂ 44 mm Hg.

Questions:

  Considering the anamnestic data and the physical examination, which are the probable causes of pulmonary hypertension?

  What tests do you suggest for confirmation?

Which treatment is the most suitable?

  Free full text is HERE!

2016 Society of Anesthesia and Sleep Medicine Guidelines on Preoperative Screening and Assessment of Adult Patients With Obstructive Sleep Apnea (free full text)

The purpose of the Society of Anesthesia and Sleep Medicine guideline on preoperative screening and assessment of adult patients with obstructive sleep apnea (OSA) is to present recommendations based on the available clinical evidence on the topic where possible. As very few well-performed randomized studies in this field of perioperative care are available, most of the recommendations were developed by experts in the field through consensus processes involving utilization of evidence grading to indicate the level of evidence upon which recommendations were based. This guideline may not be appropriate for all clinical situations and all patients. The decision whether to follow these recommendations must be made by a responsible physician on an individual basis. Protocols should be developed by individual institutions taking into account the patients’ conditions, extent of interventions and available resources. 

This practice guideline is not intended to define standards of care or represent absolute requirements for patient care. The adherence to these guidelines cannot in any way guarantee successful outcomes and is rather meant to help individuals and institutions formulate plans to better deal with the challenges posed by perioperative patients with OSA. These recommendations reflect the current state of knowledge and its interpretation by a group of experts in the field at the time of publication. While these guidelines will be periodically updated, new information that becomes available between updates should be taken into account. Deviations in practice from guidelines may be justifiable and such deviations should not be interpreted as a basis for claims of negligence.

Free full text:

http://journals.lww.com/anesthesia-analgesia/Fulltext/2016/08000/Society_of_Anesthesia_and_Sleep_Medicine.22.aspx

2016 Official American Thoracic Society Research Statement: Impact of Mild Obstructive Sleep Apnea in Adults

Background: Mild obstructive sleep apnea (OSA) is a highly prevalent disorder in adults; however, whether mild OSA has significant neurocognitive and cardiovascular complications is uncertain.

Objectives: The specific goals of this Research Statement are to appraise the evidence regarding whether long-term adverse neurocognitive and cardiovascular outcomes are attributable to mild OSA in adults, evaluate whether or not treatment of mild OSA is effective at preventing or reducing these adverse neurocognitive and cardiovascular outcomes, delineate the key research gaps, and provide direction for future research agendas.

Methods: Literature searches from multiple reference databases were performed using medical subject headings and text words for OSA in adults as well as by hand searches. Pragmatic systematic reviews of the relevant body of evidence were performed.

Results: Studies were incongruent in their definitions of “mild” OSA. Data were inconsistent regarding the relationship between mild OSA and daytime sleepiness. However, treatment of mild OSA may improve sleepiness in patients who are sleepy at baseline and improve quality of life. There is limited or inconsistent evidence pertaining to the impact of therapy of mild OSA on neurocognition, mood, vehicle accidents, cardiovascular events, stroke, and arrhythmias.

Conclusions: There is evidence that treatment of mild OSA in individuals who demonstrate subjective sleepiness may be beneficial. Treatment may also improve quality of life. Future research agendas should focus on clarifying the effect of mild OSA and impact of effective treatment on other neurocognitive and cardiovascular endpoints as detailed in the document.

Read More:

http://www.atsjournals.org/doi/suppl/10.1164/rccm.201602-0361ST