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• W2315694438 abstract "Free AccessNew ResearchHospital Sleep Medicine: The Elephant in the Room? Sunil Sharma, M.D., F.A.A.S.M. Sunil Sharma, M.D., F.A.A.S.M. Address correspondence to: Sunil Sharma, M.D., F.A.A.S.M., Associate Professor of Medicine, Director, Pulmonary Sleep Medicine, Associate Director, Jefferson Sleep Disorders Center, Thomas Jefferson University and Hospitals, 211 South Ninth Street, Suite 500, Philadelphia, PA 19107(215) 955-8285(215) 955-9783 E-mail Address: [email protected] Jefferson Sleep Disorders Center, Thomas Jefferson University and Hospitals, Philadelphia, PA Search for more papers by this author Published Online:October 15, 2014https://doi.org/10.5664/jcsm.4100Cited by:12SectionsPDF ShareShare onFacebookTwitterLinkedInRedditEmail ToolsAdd to favoritesDownload CitationsTrack Citations AboutINTRODUCTIONDespite extensive data on cardiovascular implications of sleep disordered breathing, we, as sleep physicians, have somehow managed to steer clear of hospital sleep medicine. Whether it was the demand of an over-stretched out-patient practice, lack of inpatient diagnostic tools or lack of reimbursement, hospital sleep medicine has been overlooked. This is emerging as a key area for improvement of a variety of comorbidities and potential area of growth for sleep medicine. Amongst hospitalized patients, a high prevalence of sleep disordered breathing (SDB) in disorders such as congestive heart failure (CHF), type-2 diabetes mellitus (DM), hypertension (HTN), atrial fibrillation and obesity hypoventilation syndrome (OHS) among others, makes the hospital a happy play ground for sleep disordered breathing in particular, and other sleep disorders in general. A study by Dr. Collop and colleagues in 2008, revealed a high prevalence (77%) of SDB in hospitalized patients.1 Recently, a study by Somers et al. associated SDB with sudden cardiac death.2 While several studies have demonstrated improvement of pump function in stable heart failure patients, a small RCT performed on acutely decompensated CHF demonstrated improved ejection fraction even in hospitalized patients.3 The critical question, however, is whether or not intervening makes a difference.In light of these studies and the changing scenario of the medical landscape, there are two studies in this issue of JCSM, which contribute to our current understanding of hospital sleep medicine. The study by Dr. Kauta and colleagues reveals the potential benefits of early intervention in hospitalized patients. The authors evaluated patients admitted to cardiac intermediate care unit (CICU), for potential SDB. Patients clinically suspected of SDB underwent an in-hospital portable sleep study (5 channel). Patients with AHI of 5 or more were offered auto-CPAP and compliance was monitored. Primary goal was read-mission in 30 days to the hospital or visit to the emergency department (ED). Of the 106 clinically screened patients, 79% were found to have SDB. Of these 81 patients, 50 were finally sent home on Auto-CPAP. The compliance data was available on 42 patients, of which 19 were deemed as compliant with the therapy. The study demonstrated that patients who were non-compliant were more likely to get admitted within 30-day period (p = 0.045).4 The study suggests that in patients with SDB, early intervention may reduce readmission rate in cardiac patients (the majority of patients had CHF). Somewhat perplexingly, despite predominantly CHF population (86%), only 20% of the patients were classified as having central sleep apnea (CSA), which is at odds with prior studies on stable and de-compensated CHF patients.5,6 The most likely explanation for this discrepancy may be due to the screening protocol favoring OSA (high BMI, loud snoring, oro-pharyngeal crowding). The small cohort of central sleep apnea patients in this study still raises the question of whether this benefit extends to CSA or is limited to obstructive sleep apnea (OSA). Another limitation of the study is the lack of data on medication compliance, which may significantly influence re-admissions. Nonetheless, these findings, if confirmed with a randomized control trial, will have significant implications on the role of hospital sleep medicine in addressing the high cost of readmissions in congestive heart failure/other cardiac patients.Fortunately, there are a few large studies pending, looking at this very issue. One such trial currently recruiting is the Cardiovascular Improvements with Minute Ventilation-targeted ASV Therapy in Heart Failure (CAT-HF) study. The primary goal of this multi-center randomized controlled trial is to determine whether early diagnosis and intervention in patients hospitalized with decompensated CHF will improve patient outcome, as measured by a composite of six minute walk distance (6MWD), cardiovascular hospitalizations, and death. This study will also assess changes in functional parameters, biomarkers, quality of life (QOL), and sleep and breathing.7Also in this issue Dr. Arora and colleagues report a 40% prevalence of high risk for OSA in elderly hospitalized patients who were screened by Berlin questionnaire. Using an actigraphy watch, the authors reported poor sleep efficiency and reduced sleep time in the high-risk population.8 The authors also highlighted poor awareness of sleep disorders among resident physicians, and lack of documentation of sleep history and sleep associated symptoms. This is further complicated by the lack of hypersomnolence reported in hospitalized patients. Since excessive daytime sleepiness is an important component of most screening tools, its use and validity in hospitalized patients needs to be established.Further exploration is required for cost effective strategies of identifying high risk hospitalized patients and determining the impact on various quality indices, including length of stay, in-hospital complications, ICU transfer or night-time adverse events in high risk populations. Additionally, the motivation and compliance of these patients diagnosed “in hospital” compared to established data in outpatient setting, will have an important bearing on the outcome.Confirmation of short and long term benefits of hospital sleep medicine in conjunction to a cost effective screening strategy could lead to a paradigm change on how we practice and view sleep medicine in hospitalized patients. As there are pressures on hospitals to account for post discharge outcomes, optimal management of SDB takes on a greater significance and urgency. With such potentially profound implications we cannot continue to ignore the elephant in the room…can we?DISCLOSURE STATEMENTDr. Sharma has received research support from Resmed.CITATIONSharma S. Hospital sleep medicine: the elephant in the room? J Clin Sleep Med 2014;10(10):1067-1068.REFERENCES1 Goring K, Collop NSleep disordered breathing in hospitalized patients. J Clin Sleep Med; 2008;4:105-110, 18468307. LinkGoogle Scholar2 Gami AS, Olson EJ, Shen WK, Wright RS, Ballman KV, Hodge DO, Herges RM, Howard DE, Somers VKObstructive sleep apnea and the risk of sudden cardiac death: a longitudinal study of 10,701 adults. J Am Coll Cardiol; 2013;62:610-6, 23770166. CrossrefGoogle Scholar3 Khayat RN, Abraham WT, Patt Bet al.In-hospital treatment of obstructive sleep apnea during decompensation of heart failure. Chest; 2009;134:991-7, 19567491. CrossrefGoogle Scholar4 Kauta SR, Keenan BT, Goldberg L, Schwab RJDiagnosis and treatment of sleep disordered breathing in hospitalized cardiac patients: a reduction in 30-day hospital readmission rates. J Clin Sleep Med; 2014;10:1051-9. LinkGoogle Scholar5 Padeletti M, Green P, Mooney AM, Basner RC, Mancini DMSleep disordered breathing in patients with acutely decompensated heart failure. Sleep Med; 2009;10:353, 18614398. CrossrefGoogle Scholar6 MacDonald M, Fang J, Pittman SD, White DP, Malhotra AThe current prevalence of sleep disordered breathing in congestive heart failure patients treated with beta-blockers. J Clin Sleep Med; 2008;4:38-42, 18350960. LinkGoogle Scholar7 Cardiovascular Improvements with Minute Ventilation-targeted ASV Therapy in Heart Failure (CAT-HF). ClinicalTrials.gov identifier NCT01953874. Google Scholar8 Shear TC, Balachandran JS, Mokhlesi B, Spampinato LM, Knutson KL, Meltzer DO, Arora VMRisk of sleep apnea in hospitalized older patients. J Clin Sleep Med; 2014;10:1061-6. LinkGoogle Scholar Previous article Next article FiguresReferencesRelatedDetailsCited byAdherence to continuous positive airway pressure reduces the risk of 30-day hospital readmission among older adults with comorbid obstructive sleep apnea and cardiovascular diseaseBailey M, Wickwire E, Somers V and Albrecht J Journal of Clinical Sleep Medicine, Vol. 18, No. 12, (2739-2744), Online publication date: 1-Dec-2022. Sleep in Hospitalized Older AdultsStewart N and Arora V Sleep Medicine Clinics, 10.1016/j.jsmc.2022.02.002, Vol. 17, No. 2, (223-232), Online publication date: 1-Jun-2022. Sleep-Disordered Breathing in Hospitalized PatientsSharma S and Stansbury R Chest, 10.1016/j.chest.2021.10.016, Vol. 161, No. 4, (1083-1091), Online publication date: 1-Apr-2022. Stewart N and Arora V Sleep in Hospitalized Patients Essentials of Sleep Medicine, 10.1007/978-3-030-93739-3_20, (453-470), . Ensuring Implementation Fidelity is Essential for Quality ImprovementStewart N and Arora V The Joint Commission Journal on Quality and Patient Safety, 10.1016/j.jcjq.2021.03.008, , Online publication date: 1-Mar-2021. Hospital screening for obstructive sleep apnea in patients admitted to a rural, tertiary care academic hospital with heart failureStansbury R, Abdelfattah M, Chan J, Mittal A, Alqahtani F and Sharma S Hospital Practice, 10.1080/21548331.2020.1799601, (1-6) Opiate Use and Escalation of Care in Hospitalized Adults with Acute Heart Failure and Sleep-disordered Breathing (OpiatesHF Study)Niroula A, Garvia V, Rives-Sanchez M, Quintos A, Decker M, Willes L, Quan S and Sharma S Annals of the American Thoracic Society, 10.1513/AnnalsATS.201902-100OC, Vol. 16, No. 9, (1165-1170), Online publication date: 1-Sep-2019. Sleep-disordered breathing in hospitalized patients with congestive heart failure: a concise review and proposed algorithmGupta A, Quan S, Oldenburg O, Malhotra A and Sharma S Heart Failure Reviews, 10.1007/s10741-018-9715-y, Vol. 23, No. 5, (701-709), Online publication date: 1-Sep-2018. Sleep in Hospitalized Older AdultsStewart N and Arora V Sleep Medicine Clinics, 10.1016/j.jsmc.2017.09.012, Vol. 13, No. 1, (127-135), Online publication date: 1-Mar-2018. Sleep Overnight Monitoring for Apnea in Patients Hospitalized with Heart Failure (SOMA-HF Study)Sharma S, Mather P, Chowdhury A, Gupta S, Mukhtar U, Willes L, Whellan D, Malhotra A and Quan S Journal of Clinical Sleep Medicine, Vol. 13, No. 10, (1185-1190), Online publication date: 15-Oct-2017. Report and Research Agenda of the American Geriatrics Society and National Institute on Aging Bedside-to-Bench Conference on Sleep, Circadian Rhythms, and Aging: New Avenues for Improving Brain Health, Physical Health, and FunctioningFung C, Vitiello M, Alessi C and Kuchel G Journal of the American Geriatrics Society, 10.1111/jgs.14493, Vol. 64, No. 12, (e238-e247), Online publication date: 1-Dec-2016. Effect of Early Intervention With Positive Airway Pressure Therapy for Sleep Disordered Breathing on Six-Month Readmission Rates in Hospitalized Patients With Heart FailureSharma S, Mather P, Gupta A, Reeves G, Rubin S, Bonita R, Chowdhury A, Malloy R, Willes L and Whellan D The American Journal of Cardiology, 10.1016/j.amjcard.2015.12.032, Vol. 117, No. 6, (940-945), Online publication date: 1-Mar-2016. Volume 10 • Issue 10 • October 15, 2014ISSN (print): 1550-9389ISSN (online): 1550-9397Frequency: Monthly Metrics History Submitted for publicationAugust 1, 2014Accepted for publicationAugust 1, 2014Published onlineOctober 15, 2014 Information© 2014 American Academy of Sleep MedicinePDF download" @default.
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