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A closed-claim analysis of anesthetic-related deaths and permanent injuries in the dental office setting was conducted in cooperation with a leading insurer of oral and maxillofacial surgeons and dental anesthesiologists. A total of 13 cases occurring between 1974 and 1989 was included. In each case, all available records, reports, depositions, and proceedings were reviewed. The following were determined for each case: preoperative physical status of the patient, anesthetic technique used (classified as either general anesthesia or conscious sedation), probable cause of the morbid event, avoidability of the occurrence, and contributing factors important to the outcome. The majority of patients were classified as American Society of Anesthesiologists (ASA) status II or III. Most patients had preexisting conditions, such as gross obesity, cardiac disease, epilepsy, and chronic obstructive pulmonary disease, that can significantly affect anesthesia care. Hypoxia arising from airway obstruction and/or respiratory depression was the most common cause of untoward events, and most of the adverse events were determined to be avoidable. The disproportionate number of patients in this sample who were at the extremes of age and with ASA classifications below I suggests that anesthesia risk may be significantly increased in patients who fall outside the healthy, young adult category typically treated in the oral surgical/dental outpatient setting.
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PMID:Major morbidity or mortality from office anesthetic procedures: a closed-claim analysis of 13 cases. 183 16

Since the interaction between disorders of the respiratory coordination and cardiovascular or cardiopulmonary regulation is still largely unknown the intention of the present investigation is to point out the coincidence of cardiac arrhythmias, such as premature ventricular capture (PVC) beats and conduction blocks, with obstructive sleep apnea (OSA). For the first time a group of more than 300 patients with suspected OSA is examined concerning risk factors and frequent diagnoses as obesity, hypertension, coronary heart disease (CHD), heart insufficiency, chronic obstructive pulmonary disease (COPD), and daytime hypoxaemia. Summarizing the results of lung function test, blood gas analysis, strain-ECG, Holter-ECG and inductive plethysmography with oxygen partial pressure measurement by ambulatory work-up the following statements can be made: PVC beats occurring markedly during sleep give hints for OSA being the underlying cause, especially if the patients are young and overweight. Hypoxaemia increasing during the apnea episodes should be considered as one possible pathogenetic mechanism. Second- and third degree conduction blocks and sinus arrest coincident very often with OSA. They suggest to be life-limiting factors the more so since they often go along with CHD or heart insufficiency. Systemic arterial hypertension and overweight have the highest prevalence in OSA, signs for heart insufficiency and daytime hypoxaemia are also significantly more frequent than in non-OSA patients. We could find no hints for direct pathogenetic coherence between CHD and OSA or between COPD and OSA, nevertheless pronounced nocturnal changes in blood gases and intrathoracic hemodynamics have important influence on the cardiopulmonary and cardiovascular system, as partly illuminated in other more pathogenetic oriented studies by the present time.
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PMID:[Cardiopulmonary risk factors in patients with sleep apnea]. 186 5

Intermittent mechanical ventilation via nasal CPAP mask was provided to 13 patients admitted to this institution for exacerbation of chronic respiratory failure. Ten suffered from COPD, two suffered from obesity hypoventilation syndrome (OHS), and one from severe hypothyroidism. All except one presented with dyspnea and hypercapnia due solely to progression of their underlying disease processes. Six of the patients with COPD and the patient with hypothyroidism responded to positive pressure ventilation by mask with improvements in blood gas values and clinical status. The remaining two patients with COPD and the two patients with OHS were unable to use the system. Four of the patients with COPD and chronic respiratory failure have been subsequently maintained on daily volume ventilation via nasal mask for about 20 months with persistent clinical and physiologic improvements. Application of volume ventilation through the nasal CPAP mask is a feasible strategy for providing long-term mechanical ventilation to selected patients with COPD and respiratory failure.
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PMID:Intermittent volume cycled mechanical ventilation via nasal mask in patients with respiratory failure due to COPD. 155 51

The respiratory system and nutrition are linked. Obesity is sometimes seen in chronic obstructive pulmonary disease (COPD), but its prevalence, the morbidity and mortality induced by it are not known. In addition, the prevalence of malnutrition is high in COPD and the more severe the COPD is, the higher percentage of malnutrition is present. Emphysematous patients are more frequently undernourished than those suffering from chronic bronchitis. Malnutrition is the consequence of the hypermetabolism induced by the higher cost of breathing in emphysema. The survival rate of these patients is negatively affected by malnutrition. A careful assessment of nutritional status must be performed in all COPD patients, especially during an episode of acute respiratory failure. When signs of malnutrition are present, a nutritional intervention should be initiated rapidly. An amount of calories sufficient to meet the energy expenditure increased by the disease must be given. Excessive intake may overstress the respiratory system whose functional reserve is limited in COPD. The diet must include a well balanced percentage of fat, carbohydrates and proteins. Preservation of the fat-free mass is the minimum goal to reach in acute respiratory failure. After the resolution of the acute phase, a gain of weight should be attempted within a rehabilitation program.
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PMID:[Nutrition in chronic obstructive bronchopneumopathy]. 195 47

The association of sex, age, relative weight, smoking and drinking habits, chronic obstructive pulmonary disease (COPD) and economic and marital status, with benign oesophageal disease (BOD) was investigated by means of a point-prevalence study of BOD in a Danish population. A total of 346 individuals, representing subjects who gave positive responses to the discriminating questions pertaining to BOD and risk factors in a previously described questionnaire, as well as control subjects, were invited to participate in a clinical examination. Invasive investigation was accepted by 175 subjects, 114 of whom were diagnosed as having BOD. A statistically significant relationship between BOD and COPD was demonstrated by univariate analysis, and later confirmed by multivariate analysis (P less than 0.01). Odds ratios suggested a non-significant association between BOD and smoking at least 20 g tobacco a day and consuming greater than or equal to 50 alcoholic drinks per week. Obesity, sex, age, marital and economic status were not risk factors for BOD.
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PMID:Risk factors for benign oesophageal disease in a random population sample. 206 10

Interactions between sleep and respiration have been noticed in several lung diseases. In COPD (chronic obstructive pulmonary disease) patients, the night sleep is delayed or shortened and deep sleep is often reduced or even absent. These disturbances are associated with hypoxaemic episodes occurring either in light slow wave sleep or in REM sleep, the former being short in duration and mild but repetitive and related to ventilatory changes, the latter prolonged, often severe, and resulting from both decrease in ventilation and alterations of ventilation-perfusion ratios. Restrictive syndrome due to interstitial pneumonia, kyphoscoliosis, neuromuscular diseases or, more commonly, to obesity or even pregnancy also alter sleep in a non-specific manner. Most of them result in hypoxia during paradoxical sleep. Unquestionably, there exists a relationship between sleep and asthma (aggravation of dyspnoea at night, reduction of peak expiratory flow when awaking, stage 2 asthmatic attacks). This relationship is probably caused by multifactorial interactions.
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PMID:[Changes in sleep and night respiration in asthma and obstructive or restrictive lung diseases]. 214 79

Snoring was investigated in a survey of respiratory disease in Hispanic-Americans of a New Mexico community. A population-based sample of 1222 adults was studied with questionnaires and measurements of height, weight, and blood pressure. The age-adjusted prevalence of regular loud snoring was 27.8% in men and 15.3% in women. Snoring prevalence increased with age and obesity in both men and women. Cigarette smoking was also associated with snoring, but chronic obstructive lung disease and alcohol consumption were not. Snorers more frequently had hypertension, ischemic heart disease, and excessive daytime sleepiness. In contrast to other studies, after adjustment for confounding factors, there was no effect of snoring on hypertension (odds ratio, 1.0; 95% confidence interval, 0.7 to 1.5), but an effect on myocardial infarction was still demonstrable (odds ratio, 1.8; 95% confidence interval, 0.9 to 3.6). The association of snoring with sleepiness suggests that respiratory disturbance of sleep related to upper airway obstruction, such as sleep apnea, occurs more frequently in snorers in this population.
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PMID:Snoring in a Hispanic-American population. Risk factors and association with hypertension and other morbidity. 231 Feb 78

Standard transthoracic ultrasound examination of the heart has provided increasingly better images since it was clinically introduced approximately 25 years ago. Although two-dimensional echocardiography is an established tool in clinical cardiology, the image qualities of conventional transthoracic approaches are sometimes unsatisfactory for various reasons, such as obesity, chronic obstructive lung disease, and changes with age in the chest wall. In these patients, transesophageal echocardiography can provide important diagnostic information because chest wall interference and intrathoracic attenuation are eliminated. Furthermore, the close vicinity of the heart and thoracic aorta to the transducer allows the use of higher frequency, near-focused focused transducer, which produces better resolution and improved signal to noise ratio. In this brief review, We discuss the diagnostic possibilities and clinical advantages of transesophageal echocardiography based on its application in more than 1,500 awake patients since 1977 in our department.
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PMID:[Clinical applications of transesophageal echocardiography]. 238 Oct 84

Few data are available regarding the prevalence and causes of false-negative auscultation (mis-auscultation) of aortic (AR), mitral (MR), or tricuspid regurgitation (TR), and there are no such data that are relevant when the patient's pretest probability of having regurgitation is unknown. The authors therefore studied 294 patients examined by pulsed Doppler echocardiography. On 755 examinations (2.57 examinations per patient), Doppler velocity patterns typical of AR, MR, or TR were found in 63, 96, and 49 patients, respectively. For all three murmurs, mis-auscultation was the rule, rather than the exception, with sensitivities of auscultation ranging from 0 to 37%, depending (but weakly) on the site of the murmur and the years of training of the observer. Specificity of auscultation was high (85% to 100%). The factors associated with the mis-auscultation of AR were poor image quality in the echocardiograms, absence of cardiomegaly, and less experience of the examiner. The probability of missing MR increased in the presence of coronary artery disease (CAD) or if the examiner had less experience. The likelihood of missing TR by auscultation was increased by CAD, obesity, chronic obstructive pulmonary disease, or the absence of cardiomegaly. This study suggests that there is a high prevalence of "silent" murmurs, and that not hearing a regurgitant murmur does not suffice to rule out the presence of regurgitation.
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PMID:Causes of false-negative auscultation of regurgitant lesions: a Doppler echocardiographic study of 294 patients. 297 89

Factors related to risk of perioperative pulmonary complications include site of incision, obstructive lung disease, prolonged anesthesia time, smoking history with productive cough, and obesity. Hypercapnia is a consistent indicator of high risk. There is no difference between spinal and general anesthesia with regard to risk of pulmonary complications. In patients being evaluated for lung resection, high-risk indicators include predicted postoperative forced expiratory volume in one second of less than 1000 mL, hypercapnia, severe dyspnea on exertion, or advanced age when it is associated with advanced cardiopulmonary disease. Newer methods of assessing cardiopulmonary reserve may prove useful in identifying which patients with one or more of these risk factors are suitable operative candidates. Prevention of postoperative complications in chronic obstructive pulmonary disease patients should begin in the preoperative period with discontinuation of smoking at least eight weeks before surgery and vigorous pulmonary toilet in the 48 to 72 hours before surgery. Prophylactic lung expansion maneuvers can be effective in decreasing the incidence of postoperative atelectasis in high-risk patients undergoing high-risk operations.
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PMID:Preoperative pulmonary evaluation. 233 Nov 91


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