Supine related obstructive sleep apnea (OSA) is the most common clinical and physiological phenotype of OSA. This condition is recognizable by patients, their families and through polysomnographic ...recordings. Commonly used definitions distinguish the presence of supine related OSA when respiratory events occur at twice the frequency when the patient lies in the supine compared to non-supine sleeping positions.
Recent physiology studies have demonstrated that airway obstruction arises more commonly in the supine position particularly at the level of the soft palate and epiglottis. Increased airway collapsibility is reliability observed supine relative to lateral position. To a lesser extent, changes in control of breathing favour less stable ventilation when the supine sleeping posture is adopted.
Many treatments have been developed and trialled to help patients avoid sleeping on their back. The last 10 years has seen the emergence of vibrotactile warning devices that are worn on the patients’ neck or chest. High quality randomized controlled trial data is accumulating on the efficacy and common pitfalls of the application of these treatments.
Neurogenic orthostatic hypotension (nOH) is common in patients with neurodegenerative disorders such as Parkinson’s disease, multiple system atrophy, pure autonomic failure, dementia with Lewy ...bodies, and peripheral neuropathies including amyloid or diabetic neuropathy. Due to the frequency of nOH in the aging population, clinicians need to be well informed about its diagnosis and management. To date, studies of nOH have used different outcome measures and various methods of diagnosis, thereby preventing the generation of evidence-based guidelines to direct clinicians towards ‘best practices’ when treating patients with nOH and associated supine hypertension. To address these issues, the American Autonomic Society and the National Parkinson Foundation initiated a project to develop a statement of recommendations beginning with a consensus panel meeting in Boston on November 7, 2015, with continued communications and contributions to the recommendations through October of 2016. This paper summarizes the panel members’ discussions held during the initial meeting along with continued deliberations among the panel members and provides essential recommendations based upon best available evidence as well as expert opinion for the (1) screening, (2) diagnosis, (3) treatment of nOH, and (4) diagnosis and treatment of associated supine hypertension.
Purpose
Patients suffering from cardiovascular autonomic failure often develop neurogenic supine hypertension (nSH), i.e., high blood pressure (BP) in the supine position, which falls in the upright ...position owing to impaired autonomic regulation. A committee was formed to reach consensus among experts on the definition and diagnosis of nSH in the context of cardiovascular autonomic failure.
Methods
As a first and preparatory step, a systematic search of PubMed-indexed literature on nSH up to January 2017 was performed. Available evidence derived from this search was discussed in a consensus expert round table meeting in Innsbruck on February 16, 2017. Statements originating from this meeting were further discussed by representatives of the American Autonomic Society and the European Federation of Autonomic Societies and are summarized in the document presented here. The final version received the endorsement of the European Academy of Neurology and the European Society of Hypertension.
Results
In patients with neurogenic orthostatic hypotension, nSH is defined as systolic BP ≥ 140 mmHg and/or diastolic BP ≥ 90 mmHg, measured after at least 5 min of rest in the supine position. Three severity degrees are recommended: mild, moderate and severe. nSH may also be present during nocturnal sleep, with reduced-dipping, non-dipping or rising nocturnal BP profiles with respect to mean daytime BP values. Home BP monitoring and 24-h-ambulatory BP monitoring provide relevant information for a customized clinical management.
Conclusions
The establishment of expert-based criteria to define nSH should standardize diagnosis and allow a better understanding of its epidemiology, prognosis and, ultimately, treatment.
Background: Majority of urologists prefer the usual prone position for percutaneous nephrolithotomy (PCNL) but due to various disadvantages of prone PCNL, several alternative positions are being ...used.
Aims and Objectives: The aim of the study was to compare the surgical outcomes of PCNL performed using supine position with those performed in the prone position.
Materials and Methods: This was a prospective and observational study. After applying inclusion criteria, 60 renal calculi patients were randomly assigned to two groups, each with 30 patients, all demographic, operative, and post-operative characteristics were recorded.
Results: Out of 60 patients, 38 (63%) patients were male and 22 (37%) were female. The mean age (in years) in prone PCNL was 45.03±17 while in supine, it was 51.7±15. Forty patients had mild, 12 had moderate, and eight had gross hydronephrosis. Stone size (mm) ranged from 20 to 55 with a mean stone size of 22.5±8.8 in prone PCNL and 23.9±13.5 in supine PCNL. The mean operative time (minutes) was 65.1±27.2 in prone PCNL and 68.7±16 in supine PCNL (P=0.068). Complete stone clearance was seen in 26 (86%) patients in prone PCNL versus 25 (83%) patients in supine PCNL. Five patients in supine PCNL had Grade 1–2 complications. There were no serious complications in either group. The mean post-operative hospital stay (days) was 3.53 in prone PCNL versus 3.63 in supine PCNL, (P=0.715).
Conclusion: Supine PCNL is an effective and safe procedure with similar operative time, stone-free rate, and complications to prone PCNL.
To review the effects of prone position and supine position on oxygenation parameters in patients with Coronavirus Disease 2019 (COVID-19).
Systematic review and meta-analysis of non-randomized ...trials.
Databases of EMBASE, MEDLINE and CENTRAL were systematically searched from its inception until March 2021.
COVID-19 patients being positioned in the prone position either whilst awake or mechanically ventilated.
Primary outcomes were oxygenation parameters (PaO₂/FiO₂ ratio, PaCO₂, SpO₂). Secondary outcomes included the rate of intubation and mortality rate.
Thirty-five studies (n = 1712 patients) were included in this review. In comparison to the supine group, prone position significantly improved the PaO₂/FiO₂ ratio (study = 13, patients = 1002, Mean difference, MD 52.15, 95% CI 37.08 to 67.22; p < 0.00001) and SpO₂ (study = 11, patients = 998, MD 4.17, 95% CI 2.53 to 5.81; p ≤0.00001). Patients received prone position were associated with lower incidence of mortality (study = 5, patients = 688, Odd ratio, OR 0.44, 95% CI 0.24 to 0.80; p = 0.007). No significant difference was noted in the incidence of intubation rate (study = 5, patients = 626, OR 1.20, 95% CI 0.77 to 1.86; p = 0.42) between the supine and prone groups.
Our meta-analysis demonstrated that prone position improved PaO₂/FiO₂ ratio with better SpO₂ than supine position in COVID-19 patients. Given the limited number of studies with small sample size and substantial heterogeneity of measured outcomes, further studies are warranted to standardize the regime of prone position to improve the certainty of evidence.
PROSPERO Registration: CRD42021234050
•Prone position improved PaO₂/FiO₂ ratio with better SpO₂ than supine position in Coronavirus Disease 2019 patients.•Prone position was associated with lower mortality rate.•Further studies are warranted to standardize the regime of prone ventilation to improve the certainty of evidence.
Prone and Supine 12-Lead ECG Comparisons Chieng, David; Sugumar, Hariharan; Kaye, David ...
JACC. Clinical electrophysiology,
November 2021, 2021-11-00, Letnik:
7, Številka:
11
Journal Article
Recenzirano
Odprti dostop
This study sought to describe expected changes in a mirror-image prone electrocardiogram (ECG) compared with normal supine, including a range of cardiac conditions.
Unwell COVID-19 patients are at ...risk of cardiac complications. Prone ventilation is recommended but poses practical challenges to acquisition of a 12-lead ECG. The effects of prone positioning on the ECG remain unknown.
100 patients each underwent 3 ECGs: standard supine front (SF); prone position with precordial leads attached to front (PF); and prone with precordial leads attached to back in a mirror image to front (PB).
Prone positioning was associated with QTc prolongation (PF 437 ± 32 ms vs. SF 432 ± 31 ms; p < 0.01; PB 436 ± 34 ms vs. SF 432 ± 31 ms; p = 0.02). In leads V1 to V3 on PB ECG, a qR morphology was present in 90% and changes in T-wave polarity in 84%. In patients with anterior ischemia, ST-segment changes in V1 to V3 on supine ECG were no longer visible on PB in 100% and replaced by an R-wave in V1. Bundle branch block (BBB) remained detectable in 100% on PB, with left BBB appearing as right BBB on PB in 71% and QRS narrowing with qR in V1 for right BBB. ST-segment/T-wave changes in limb leads and arrhythmia detection were largely unaffected in PB.
As expected, the PB ECG is unreliable for the detection of anterior myocardial injury but remains useful for ST-segment/T-wave abnormalities in limb leads, BBB detection, and rhythm monitoring. The prone ECG is a useful screening tool with diagnostic utility in COVID-19 patients who require prone ventilation.
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Purpose
This study aimed to determine the prevalence of positional obstructive sleep apnea (OSA) and its subtypes in Korean adults with newly diagnosed OSA and document the clinical characteristics ...of positional OSA and its subtypes compared to non-positional OSA
Methods
In this cross-sectional study, we evaluated 1052 OSA adults. Positional OSA was defined as an overall apnea-hypopnea index (AHI) ≥5 and supine AHI to non-supine AHI ratio of ≥2. Positional OSA was subtyped depending on the degree of AHI while in the non-supine position: subtype I (a non-supine AHI <5/h), subtype II (a non-supine AHI ≥5/h and <15/h), and subtype III (a non-supine AHI ≥15/h). To compare clinical characteristics between patient groups depending on the positional tendency of OSA, statistical analyses were performed.
Results
The prevalence of positional OSA was 75.6 % with 39.9 % having AHI normalized <5/h while in non-supine position. Positional OSA patients had milder OSA, older age, and lower BMI than did non-positional OSA patients. However, having positional OSA did not influence daytime sleepiness, depressive symptoms, anxiety, and health-related quality of life. Unlike the subtype I and II positional OSAs, subtype III did not differ in clinical features from non-positional OSA. There were significant differences in supine sleep time depending on the positional tendency of OSA. Subtype III positional OSA had the shortest supine sleep time whereas subtype I positional OSA and non-positional OSA had the longest supine sleep time.
Conclusions
Positional OSA subtypes have different clinical characteristics. Subtyping of positional OSA is helpful for developing specific treatment strategies according to positional tendency
Moderate-intensity aerobic exercise increases cerebral blood velocity (CBv) primarily due to hyperpnea-induced vasodilation; however, the integrative control of cerebral blood flow (CBF) allows other ...factors to contribute to the vasodilation. Although lower body negative pressure (LBNP) can reduce CBv, the exact LBNP intensity required to blunt the aforementioned exercise-induced CBv response is unknown. This could hold utility for concussion recovery, allowing individuals to exercise at higher intensities without symptom exacerbation. Thirty-two healthy adults (age: 20-33 yr; 19 females/13 males) completed a stepwise maximal exercise test during a first visit to determine each participant's wattage associated with their exercise-induced maximal CBv increase. During the second visit, following supine rest, participants completed moderate-intensity exercise at their determined threshold, while progressive LBNP was applied at 0, -20, -40, -60, -70, -80, and ∼88 Torr. Bilateral middle cerebral artery blood velocities (MCAvs), mean arterial pressure (MAP), heart rate, respiratory rate, and end-tidal carbon dioxide levels were measured continuously. Two-way analysis of variance with effect sizes compared between sexes and stages. Compared with resting supine baseline, averaged MCAv was elevated during 0 and -20 Torr LBNP (
value > 7.73;
< 0.001); however, no differences were noted between baseline and -40 to -70 Torr (
value < |4.24|;
> 0.262). Differences were present between females and males for absolute MCAv measures (
value > 11.2;
< 0.001), but not when normalized to baseline (
value < 0.03;
> 0.951). Supine cycling-elicited increases in MCAv are able to be blunted during the application of LBNP ranging from -40 to -70 Torr. The blunted CBv response demonstrates the potential benefit of allowing individuals to aerobically train (moderate-intensity supine cycling with LBNP) without exacerbating symptoms during the concussion recovery phase.
The current investigation demonstrated that moderate-intensity supine cycling-induced increases in cerebral blood velocities were balanced by the lower body negative pressure-induced decreases in cerebral blood velocity. Although performed in a healthy population, the results may lend themselves to a potential treatment option for individuals recovering from concussion or experience persistent concussion symptoms.
Highlights • The association between supine sleep position and increased obstructive sleep apnea is well known. • In the present study, severe obstructive sleep apnea syndrome (OSAS) in people with ...Parkinson's disease is associated with a reduced number of position changes at night. • In the present study, severe OSAS in people with PD is associated with an increased supine sleep position at night. • For people with PD, treating the difficulties of turning around in bed may be helpful.
Summary The most striking feature of obstructive respiratory events is that they are at their most severe and frequent in the supine sleeping position: indeed, more than half of all obstructive sleep ...apnea (OSA) patients can be classified as supine related OSA. Existing evidence points to supine related OSA being attributable to unfavorable airway geometry, reduced lung volume, and an inability of airway dilator muscles to adequately compensate as the airway collapses. The role of arousal threshold and ventilatory control instability in the supine position has however yet to be defined. Crucially, few physiological studies have examined patients in the lateral and supine positions, so there is little information to elucidate how breathing stability is affected by sleep posture. The mechanisms of supine related OSA can be overcome by the use of continuous positive airway pressure. There are conflicting data on the utility of oral appliances, while the effectiveness of weight loss and nasal expiratory resistance remains unclear. Avoidance of the supine posture is efficacious, but long term compliance data and well powered randomized controlled trials are lacking. The treatment of supine related OSA remains largely ignored in major clinical guidelines. Supine OSA is the dominant phenotype of the OSA syndrome. This review explains why the supine position so favors upper airway collapse and presents the available data on the management of patients with supine related OSA.
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