Chapter 37: Pulmonary Disorders

APNEA, CENTRAL SLEEP (CSAS)

Population

• Adults.

Recommendations

American Academy of Sleep Medicine 2012

• Primary CSAS

  • Use positive airway pressure therapy.

  • Limited evidence to support the use of acetazolamide for CSAS.

  • Consider zolpidem or triazolam if patients are not at high risk for respiratory depression.

• CSAS related to CHF

  • Nocturnal oxygen therapy.

  • CPAP therapy targeted to normalize the apnea-hypopnea index.

• CSAS related to ESRD

  • Options for therapy include CPAP, nocturnal oxygen, and bicarbonate buffer use during dialysis.

Source

• http://www.guideline.gov/content.aspx?id=35175

APNEA, OBSTRUCTIVE SLEEP (OSA)

Population

• Adults.

Recommendations

AASM 2017

• Recommends that diagnostic testing for OSA be performed in conjunction with a comprehensive sleep evaluation.

• Recommends that a polysomnogram, or home sleep apnea testing with a technically adequate device, be used for the diagnosis of OSA in uncomplicated adult patients presenting with signs and symptoms that indicate an increased risk of moderate-to-severe OSA.

• Recommends that a polysomnogram, rather than home sleep apnea testing, be used for the diagnosis of OSA in patients with significant cardiorespiratory disease, potential respiratory muscle weakness due to neuromuscular condition, awake hypoventilation or suspicion of sleep-related hypoventilation, chronic opioid medication use, and history of stroke or severe insomnia.

• Recommends that if a single home sleep apnea testing is negative, inconclusive, or technically inadequate, a polysomnogram be performed for the diagnosis or exclusion of OSA.

Sources

• http://guidelines.gov/summaries/summary/50887/

• Kapur VK, Auckley DH, Chowdhuri S, et al. Clinical practice guideline for diagnostic testing for adult obstructive sleep apnea: an American Academy of Sleep Medicine clinical practice guideline. J Clin Sleep Med. 2017;13(3):479-504.

ACP 2013

• Encourage all overweight adults diagnosed with OSA to lose weight.

• Use nocturnal CPAP (continuous positive airway pressure) therapy as first-line therapy for OSA.

• Option to use mandibular advancement devices for those patients intolerant of CPAP.

Source

• http://www.guideline.gov/content.aspx?id=47136

ASTHMA, EXACERBATIONS

Population

• Children >5 y and adults.

Recommendations

GINA 2018

• Assess severity of asthma exacerbation while starting SABA and supplemental oxygen as needed.

• Consider alternative causes for the patient’s respiratory symptoms. Consider anaphylaxis.

• Arrange for transfer of patient to acute care facility if there are signs of severe exacerbation, altered mentation, or silent chest. Give inhaled SABA, inhaled ipratropium bromide, oxygen, and systemic corticosteroids as soon as possible while awaiting/arranging for transfer.

• Start treatment with repeated doses of inhaled SABA, early oral corticosteroids, and supplemental oxygen. Titrate oxygen to maintain oxygen saturation 93%–95% in adults, and 94%–98% in children ages 6–12 y.

• For severe exacerbations, add ipratropium bromide, consider inhaled nebulized SABA. Consider IV magnesium if ...