Association of CPAP bacterial colonization with chronic rhinosinusitis

Level of Contamination of Positive Airway Pressure Devices Used in Obstructive Sleep Apnea

OBJECTIVES

No study has yet evaluated the degree of contamination after the total disassembly of continuous positive airway pressure (CPAP) devices. We investigated the extent of contamination of CPAP devices used daily by patients with obstructive sleep apnea (OSA) by disassembling the systems and identifying the factors that influenced the degree of CPAP contamination.

METHODS

We conducted a chart review of the medical records of patients with OSA for whom the CPAP devices were disassembled and cleaned. Two skilled technicians photographed the levels of contamination of each component and scored them using a visual analog scale. Patients' clinical characteristics and records of CPAP device usage were statistically analyzed to identify characteristics that were significantly associated with the degree of CPAP device contamination.

RESULTS

Among the 55 participants, both the external components, including the mask and tube, and the internal components, such as the humidifier and the interior of the main body, showed a substantial degree of contamination. The total and average daily duration of usage of the CPAP device did not show significant associations with the degree of contamination. Age was most consistently associated with the degree of contamination, such as in masks, humidifiers, and interior and exterior main parts. The degree of contamination of the internal components of the device was significantly correlated with the degree of contamination of the external components.

CONCLUSION

Age-specific guidelines for managing the hygiene of external and internal CPAP components should be prepared.

Respiratory infection risk in positive airway pressure therapy users: a retrospective cohort study

STUDY OBJECTIVES

Concerns regarding the risk of positive airway pressure (PAP)-associated respiratory infection (RI) have shaped consumer views toward PAP device use and maintenance. However, data regarding temporal associations between PAP use and risk for RIs are limited. The purpose of the present study was to examine longitudinal associations between PAP use and risk of clinically significant RIs in a cohort of patients with obstructive sleep apnea.

METHODS

The frequency of clinically reported respiratory RIs pre- and post-PAP use were compared in a sample of 482 adult patients with obstructive sleep apnea who underwent PAP titration at a large academic sleep center between 2011 and 2014. RIs were identified by clinical record review beginning two years before and ending two years after the participants' PAP titration. Presence of longitudinal standard PAP data download reports identified PAP users from nonusers. PAP adherence was defined as at least 4 hours of use per day, five days per week for at least 70% of days. Poisson regression models, adjusted for age, sex, body mass index, and the number of pre-PAP use RIs were utilized to examine associations between PAP use and subsequent RIs.

RESULTS

Poisson regression models adjusted for age, sex, body mass index, and the number of pre-PAP use RIs did not show associations between PAP therapy use and rate of post-PAP use RIs (rate ratio = 1.27, 95% confidence interval: 0.86-1.86). A sensitivity analysis that included only PAP users with difference in PAP adherence showed similar results (rate ratio = 0.65, 95% confidence interval: 0.32-1.30).

CONCLUSIONS

Among adults with obstructive sleep apnea, we did not find evidence for association between PAP use/adherence and increased RI frequency. These data offer new information that could assuage patients with obstructive sleep apnea who are considering PAP deferral based on RI concerns.

CITATION

Gavidia R, Shieu MM, Dunietz GL, Braley TJ. Respiratory infection risk in positive airway pressure therapy users: a retrospective cohort study. J Clin Sleep Med. 2023;19(10):1769-1773.

Comparative Incidence of Periocular Surgical Site Infections with Increased Surgical Mask Use during the COVID-19 Pandemic

PURPOSE

To evaluate the effect of surgical mask use on infection rates for office-based periocular surgeries during the pandemic.

METHODS

An Institutional Review Board-approved retrospective review of medical records identified patients who had an office-based oculofacial plastic surgery procedure during the pandemic between March and December 2020. Statistical analysis was used to compare this group to patients that underwent procedures between March and December 2019, prior to the pandemic when neither surgeon nor patient wore a surgical mask.

RESULTS

The study consisted of 680 patients. Thirty-one different types of procedures were encountered. The incidence of infections in 2020 compared to 2019 was not statistically significant (1.12% (n = 3) versus 1.21% (n = 5), p = 1). All patients with infections were treated with oral antibiotics and improved without long-term complications.

CONCLUSIONS

Periocular surgical site infections are uncommon, and the wearing of surgical masks by patient and surgeon during our office-based oculofacial procedures did not change the incidence of SSIs.

Pneumocystis jirovecii pneumonia presenting as a solitary pulmonary granuloma due to unclean continuous positive airway pressure equipment: a case report

Continuous positive airway pressure (CPAP) therapy can spread infections if the equipment is not cleaned properly. We report a case of Pneumocystis jirovecii pneumonia likely spread by unclean CPAP equipment and accessories. A 48-year-old man with severe obstructive sleep apnea was using CPAP equipment that had never been cleaned for 5 years. He experienced intermittent mild fever for 6 weeks. His chest images showed a solitary pulmonary granuloma. Pneumocystis jirovecii was identified from the bronchoalveolar fluid, the CPAP mask, and the air tubing. The fever subsided immediately after changing to a clean CPAP device. We prescribed sulfamethoxazole 400 mg and trimethoprim 80 mg twice daily for one month. Three months later, the pulmonary granuloma disappeared, and Pneumocystis jirovecii was absent in the bronchoalveolar fluid. Poorly cleaned CPAP devices could harbor Pneumocystis jirovecii and spread pulmonary infection in immunocompetent persons. Appropriate cleaning of CPAP equipment is essential to minimize infection risk.

Positive Airway Pressure Therapy Adherence with Mask Resupply: A Propensity-Matched Analysis

There are currently few data on the impact of mask resupply on longer-term adherence to positive airway pressure (PAP) therapy. This retrospective analysis investigated the effects of mask/mask cushion resupply on the adherence to PAP versus no resupply. Deidentified patient billing data for PAP supply items were merged with telemonitoring data from Cloud-connected AirSense 10/AirCurve 10 devices via AirView^TM (ResMed). Eligible patients started PAP between 1 July 2014 and 17 June 2016, had ≥360 days of PAP device data, and achieved initial U.S. Medicare adherence criteria. Patients who received a resupply of mask systems/cushions (resupply group) were propensity-score-matched with those not receiving any mask/cushion resupply (control group). A total of 100,370 patients were included. From days 91 to 360, the mean device usage was 5.6 and 4.5 h/night in the resupply and control groups, respectively (p < 0.0001). The proportion of patients with a mean device usage ≥4 h/night was significantly higher in the resupply group versus the control group (77% vs. 59%; p < 0.0001). The therapy termination rate was significantly lower in the resupply group versus the control group (14.7% vs. 31.9%; p < 0.0001); there was a trend toward lower therapy termination rates as the number of resupplies increased. The replacement of mask interface components was associated with better longer-term adherence to PAP therapy versus no resupply.

Intracranial Epidural Abscess in a 9-Year-Old Boy With Precocious Puberty and Use of Continuous Positive Airway Pressure

Intracranial extension of rhinosinusitis is rare in children. We report a 9-year-old immunocompetent boy with central precocious puberty and obstructive sleep apnea-hypopnea syndrome who developed an intracranial epidural abscess secondary to rhinosinusitis while on continuous positive airway pressure (CPAP) treatment. A retrospective review of the medical record and imaging studies was performed. MEDLINE and Cochrane databases were searched for reports of epidural abscess developing in patients receiving CPAP treatment or in patients with precocious puberty. Intracranial extension of frontal rhinosinusitis is more common during puberty probably because of the active growth of the frontal sinuses and their rich blood supply. Controlled studies show no increase with rhinosinusitis in adults on CPAP; no published studies assess intracranial extension of rhinosinusitis in CPAP use. Patients with unexplained, severe headache and fever following CPAP use may require neuroimaging (magnetic resonance imaging [MRI] / contrast computed tomography) to rule out intracranial extension of sinusitis.

Non Cystic Fibrosis Bronchiectasis-new clinical approach, management of treatment and pulmonary rehabilitation

Abstract Non-Cystic Fibrosis Bronchiectasis (NCFB) are characterised by abnormal, permanently damaged and dilated bronchi due to the innapropiate clearence of various microorganisms and recurrent chronic infections.The diagnosis is suggested by the clinical presentation and is confirmed by multiple investigations. There are some comorbidities associated with bronhciectasis, such as chronic obstructive pulmonary disease (COPD), cardiovascular disorders, gastro-esophageal reflux disease (GERD), psychological illnesses, pulmonary hypertension, obstructive apnea syndrome(OSA). The condition has a substantial socioeconomic impact because it requests a multidisciplinary management and periods of exacerbations are common. The aims of the management of bronchiectasis are to reduce symptoms (such as sputum volume and purulence, cough and dyspnea), reduce the frequency and severity of exacerbations, preserve lung function and improve health-related quality of life. The multidisciplinary approach of bronchiectasis patients require along with the medical treatment, a specific plan of nonphamarcological strategies, including balneological intervention. There are a lot of techniques improving the airway clearence, such as: active cycle of breathing techniques (which include breathing control, thoracic expansion exercises, forced expiratory technique), oscilatting possitive expiratory pressure, autogenic drainage, gravity-assisted-positioning, modified postural drainage. Together with specific medication, these techniques can diminuate symptoms and improve the quality of life. Key words: NCFB, airway clearence, physiotherapy,

Late-onset bleb-associated endophthalmitis and continuous positive airway pressure

PURPOSE

To raise awareness of a possible association between continuous positive airway pressure (CPAP) devices and postoperative bleb-related infection.

OBSERVATIONS

A 57-year old patient on CPAP presented with unilateral bleb-associated endophthalmitis 32 months after routine ExPress Trabeculectomy with mitomycin C. The offending organism, Streptococcus mitis, is a nonmotile and generally non-virulent pathogen which predominates in the normal human respiratory flora.

CONCLUSIONS AND IMPORTANCE

This conceptual report underscores a potential relationship between CPAP use and bleb-associated endophthalmitis. Streptococcal species are the most commonly reported causative organisms in bleb-associated endophthalmitis, and S. mitis is of particular concern as the most abundant microbe among all human oral flora. A logical risk factor for infection, the CPAP device may inadvertently deliver such organisms to the vulnerable conjunctival filtering bleb.

Sleep disruption in chronic rhinosinusitis

INTRODUCTION

Chronic rhinosinusitis (CRS) is a common disease of the upper airways and paranasal sinuses with a marked decline in quality of life (QOL). CRS patients suffer from sleep disruption at a significantly higher proportion (60 to 75%) than in the general population (8-18 %). Sleep disruption in CRS causes decreased QOL and is linked to poor functional outcomes such as impaired cognitive function and depression. Areas covered: A systematic PubMed/Medline search was done to assess the results of studies that have investigated sleep and sleep disturbances in CRS. Expert commentary: These studies reported sleep disruption in most CRS patients. The main risk factors for sleep disruption in CRS include allergic rhinitis, smoking, and high SNOT-22 total scores. The literature is inconsistent with regard to the prevalence of sleep-related disordered breathing (e.g. obstructive sleep apnea) in CRS patients. Although nasal obstruction is linked to sleep disruption, the extent of sleep disruption in CRS seems to expand beyond that expected from physical blockage of the upper airways alone. Despite the high prevalence of sleep disruption in CRS, and its detrimental effects on QOL, the literature contains a paucity of studies that have investigated the mechanisms underlying this major problem in CRS.

Continuous Positive Airway Pressure: Is it a route for infection in those with Obstructive Sleep Apnoea?

INTRODUCTION

Continuous positive airway pressure (CPAP) is the standard treatment for obstructive sleep apnoea (OSA), with limited data about the prevalence of respiratory infections and microbial colonization in these patients.

OBJECTIVES

The aim of this study was to determine if CPAP use is associated with respiratory infections and to identify the organisms that colonize or infect these patients.

METHOD

A retrospective, case-controlled study in patients diagnosed with OSA was carried out. 137 patients were recruited and interviewed using a questionnaire. A nasal swab was taken from each patient. Patients using CPAP machines had swabs taken from masks and humidifiers.

RESULTS

66 (48.2%) patients received CPAP treatment with 60.6% of them having a heated humidifier. 78.8% were male, with the majority using a full face mask (63.6%). No significant difference was seen in the prevalence of rhinosinusitis, lower respiratory tract infections and hospital admissions for pneumonia between CPAP and non-CPAP treated patients. The presence of a humidifier did not influence the prevalence of infections. Commensal flora was predominantly cultured from nasal swabs from both patient groups. Coagulase Negative Staphylococci and Diphtheroids were the main organisms cultured from masks and humidifiers respectively.

CONCLUSIONS

This study shows that the use of CPAP, choice of mask and humidifier have no significant impact on the prevalence of infections and micro-organisms isolated. This is very reassuring to the physician prescribing CPAP therapy and users.

Evaluation of bacterial transmission to the paranasal sinuses through sinus irrigation

BACKGROUND

Saline nasal irrigation is effective in the treatment of sinonasal disorders, including chronic rhinosinusitis (CRS). Despite bacterial contamination in rinse bottles and reports of infections from contaminated irrigation water, tap water is still used by ∼50% of irrigation users, raising a potential public health concern. This study aimed to determine whether bacteria from the water supply used in sinus irrigations colonizes the paranasal sinuses.

METHODS

Samples were taken from the: (1) water used for irrigation, (2) faucet or container the water originated from, (3) rinse bottle, and (4) postoperative ethmoid cavity from 13 subjects with CRS. Microbiota were characterized using quantitative polymerase chain reaction (qPCR) and 16S ribosomal RNA (rRNA) gene sequencing. The Morisita-Horn beta-diversity index (M-H) was used to assess similarity in microbiota between samples, and genomic analysis was performed to assess clonality of cultured bacteria.

RESULTS

Of 13 subjects, 6 used distilled water, 6 used tap water, and 1 used well water in this institutional review board (IRB)-approved observational study. Well-water had markedly more bacteria than tap or distilled water. There was a trend toward tap having more bacteria than distilled water. The sinus samples were notably dissimilar to the bottle, faucet, and irrigant (M-H 0.15, 0.09, and 0.18, respectively). There was no difference in postoperative microbiotas between distilled and tap water users.

CONCLUSION

The current study suggests that irrigation plays little role in establishing the sinus microbiome. Although rinsing with tap water may never be formally recommended, these data are useful to counsel patients who prefer to do so in non-endemic areas if the municipal water supply is appropriately treated.