Primary Care Medicine

Pulmonary & Sleep Medicine

Primary Care Medicine

Pulmonary & sleep Medicine Consultations by Dr. Taj M Jiva, MD, MPH, JD

531Center Road. Suite 2. West Seneca, NY 14224

Phone: 939-8899

[email protected]

phoenixrisingsleepmedicine.com

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 countries.

4For healthcare personnel, testing may be considered if there has been exposure to a person with suspected COVID-19 without laboratory confirmation.

5Category includes single or clusters of patients with severe acute lower respiratory illness (e.g., pneumonia, ARDS) of unknown etiology in which COVID-19 is

being considered.

6Fever may be subjective or confirmed.

Does the person have fever6 and

symptoms of lower respiratory illness

(e.g., cough, shortness of breath)?

Does the person have an alternative

explanatory diagnosis (e.g., influenza)?

YES NO YES NO YES NO

STOP: No COVID-19 testing needed

Continue to treat patient normally.

A. Person traveled to or from an

affected geographic area1 with

widespread or sustained community

transmission.

B. Person had close contact2 with a

laboratory-confirmed3,4

COVID-19 patient

C. Person with severe acute lower

respiratory illness5 and fever

requiring hospitalization.

This patient meets the criteria for a patient under investigation for COVID-19. The Florida Department of Health asks

that you immediately notify both infection control personnel at your health care facility and your county health department

(FloridaHealth.gov/CHDEpiContact).

Content source: Centers for Disease Control and Prevention

Version 2 | February 28, 2020

Only consider persons with travel to an affected geographic area1 or close contact2 with a laboratory-confirmed3,4 COVID-19

patient within 14 days of symptom onset or persons with severe respiratory illness5 without an alternative diagnosis.

• Ask the patient to wear a surgical mask.

• Evaluate the patient in a private room with the door closed, ideally an airborne isolation room, if available.

• Initiate contact and airborne precautions, including use of eye protection (e.g., goggles or a face shield) for all health care

professionals and other staff entering the room.

• Visit www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control.html for additional recommendations on infection control

recommendations for patients under investigation for COVID-19 in health care settings.

C


Adult Preventive Health Care Schedule: Recommendations from the USPSTF


Grade A/B Recommendations (with Associated Grade C/D/I Recommendations):


Alcohol misuse screening

(B) Screen adults and provide brief behavioral interventions for risky alcohol use


Depression screening

(B) Screen adults with systems for evaluation and management


Hypertension screening

(A) Screen adults; exclude white coat hypertension before starting therapy


Obesity screening

(B) Screen adults and offer or refer patients with body mass index ≥ 30 kg per m2 to intensive behavioral interventions


Tobacco use screening

(A) Screen adults and provide behavioral and U.S. Food and Drug Administration–approved intervention therapy for cessation

(I) IETRFOA electronic nicotine delivery systems for tobacco cessation


Human immunodeficiency virus screening

(A) Screen individuals 15 to 65 years of age

(A) Screen older and younger persons who are at increased risk


Hepatitis B virus infection screening7

(B) Screen adolescents and adults at high risk

Syphilis screening8 (UIP)

(A) Screen individuals at increased risk

(D) Recommend against routine screening if normal risk


BRCA screening

(B) Screen women with appropriate family history

(D) Recommend against screening patients without appropriate family history


Chlamydia and gonorrhea screening

(B) Screen sexually active women 24 years and younger, and women at increased risk who are 25 years and older

(I) IETRFOA screening sexually active males


Intimate partner violence screening

(B) Screen women of childbearing age and refer to appropriate services

(I) IETRFOA screening all vulnerable and elderly patients for abuse or neglect


Cervical cancer screening (UIP)

(A) Screen women 21 to 65 years of age

Papanicolaou smear every three years

Women 30 to 65 years of age may increase screening interval to five years with cytology and human papillomavirus cotesting

(D) Recommend against screening in women

Age 20 years and younger

Older than 65 years if adequately screened previously and no increased risk of cervical cancer

With hysterectomy (including cervix) without history of cervical intraepithelial neoplasia grade 2 or 3 or cervical cancer

Younger than 30 years with human papillomavirus testing alone or in combination with cytology


Lipid disorder screening (UIP)

(A) Screen men 35 years and older

(A) Screen women 45 years and older at increased risk of CHD

(B) Screen men 20 to 35 years of age and women 20 to 45 years of age at increased CHD risk

(C) No recommendations for or against screening men 20 to 35 years of age and women 20 to 45 years of age without increased CHD risk


Abnormal glucose and diabetes mellitus type 2 screening

(B) Screen overweight or obese adults 40 to 70 years of age and refer patients with abnormal glucose levels for intensive counseling for healthy diet and exercise


Hepatitis C virus infection screening

(B) Offer one-time screening of patients born between 1945 and 1965

(B) Screen high-risk patients


Colorectal cancer screening (UIP)

(A) Screen patients 50 to 75 years of age with fecal occult blood testing, sigmoidoscopy, or colonoscopy

(C) Recommend against routine screening of patients 76 to 85 years of age

(D) Recommend against screening patients 86 years and older

(I) IETRFOA for screening with computed tomography colonography or fecal DNA


Breast cancer screening17

(B) Biennial screening mammography in women 50 to 74 years of age

(C) Screening is an individualized decision for women 40 to 49 years of age

(I) IETRFOA

Mammography after 75 years of age

Screening with digital breast tomosynthesis

Adjunctive screening in women with dense breast tissue and negative screening mammogram


Lung cancer screening

(B) Screen annually with low-dose computed tomography for individuals 55 to 80 years of age with a 30 pack-year history who currently smoke or quit within the past 15 years; consider overall health in decision to screen


Osteoporosis screening (UIP)

(B) Screen women 65 years and older

(B) Screen women if fracture risk equal to that of a 65-year-old white woman without other risk factors (9.3% in 10 years by U.S. FRAX [Fracture Risk Assessment] tool)

(I) IETRFOA screening men


Abdominal aortic aneurysm screening

(B) Screen men 65 to 75 years of age who ever smoked (100 or greater lifetime cigarettes) with one-time abdominal aortic aneurysm ultrasonography

(C) Recommend selective screening of never-smoking men 65 to 75 years of age

(I) IETRFOA women 65 to 75 years of age who ever smoked

(D) Recommend against routine screening in never-smoking women 65 to 75 years of age


Primary prevention of breast cancer 

(B) Recommend shared decision making for medications (such as tamoxifen and raloxifene) that reduce risk of breast cancer in women at increased risk

(D) Recommend against routine use if no increased risk

Folic acid supplementation22 (UIP)

(A) 0.4 to 0.8 mg daily for women capable of conception


Aspirin for cardiovascular risk reduction23 (UIP)

(A) Recommend aspirin use in men 45 to 79 years of age for reduction in myocardial infarction if benefit outweighs risk

(A) Recommend aspirin use in women 55 to 79 years of age for reduction in ischemic stroke if benefit outweighs risk

(I) IETRFOA aspirin for primary prevention of 

cardiovascular risk reduction in individuals 80 years and older

(D) Recommend against use of aspirin for CVD primary prevention in men younger than 45 years and women younger than 55 years


Fall prevention in older adults (UIP)

(B) Recommend exercise or physical therapy and vitamin D supplementation for fall prevention in community-dwelling individuals 65 years and older at increased risk of falls

(C) Recommend against automatic comprehensive screening for fall risk in community-dwelling older adults


Counseling to prevent sexually transmitted infection


(B) Recommend counseling to prevent sexually transmitted infection for adolescents and adults at increased risk


Counseling to promote healthy diet and physical activity 

(B) Recommend that overweight or obese patients with other CVD risk factor(s) be offered or referred for intensive behavioral counseling


Counseling for skin cancer prevention

(B) Recommend counseling fair-skinned patients 10 to 24 years of age about minimizing ultraviolet light exposure

(I) IETRFOA counseling individuals older then 24 years about reducing risk of skin cancer


Grade C Recommendations:


Physical activity and healthy diet counseling to reduce cardiovascular risk (UIP)

Grade D Recommendations:


Aspirin or nonsteroidal anti-inflammatory drugs for prevention of colorectal cancer (UIP)


Bacteriuria (asymptomatic) screening in men and nonpregnant women


Beta carotene or vitamin E supplementation for CVD or cancer risk reduction


Carotid artery stenosis screening


CHD screening with resting or exercise electrocardiography in low-risk patients


Chronic obstructive pulmonary disease screening with spirometry 


Combined estrogen-progesterone for prevention of chronic conditions or estrogen for the same in patients with hysterectomy (UIP)


Genital herpes screening (UIP)


Ovarian cancer screening(UIP)


Pancreatic cancer screening


Prostate cancer screening with prostate-specific antigen (UIP)


Testicular cancer screening


Vitamin D screening in community-dwelling nonpregnant adults


Vitamin D (≤ 400 IU) and calcium (≤ 1,000 mg) supplementation daily for primary prevention of fracture in noninstitutionalized postmenopausal women


Grade I Recommendations:


Bladder cancer screening


CHD screening with nontraditional risk factors(UIP)

CHD screening with resting or exercise 


electrocardiography in intermediate- to high-risk patients


Chronic kidney disease screening


Cognitive impairment screening in older adults


Combined vitamin D and calcium supplementation in men or premenopausal women


Hearing loss screening in older adults


Illicit drug use screening


Impaired visual acuity screening in older adults


Multivitamin, single nutrient or paired nutrients for CVD or cancer risk reduction (beta carotene and vitamin E, as above)


Oral cancer screening


Peripheral artery disease and CVD risk screening with ankle-brachial index


Primary open-angle glaucoma screening


Skin cancer screening (whole body) in primary care (UIP)


Suicide risk screening


Thyroid dysfunction screening


Vitamin D (> 400 IU) and calcium (> 1,000 mg) supplementation daily for primary prevention of fracture in noninstitutionalized postmenopausal women


The CDC Prevention Guidelines Database


The Prevention Guidelines Database is a comprehensive compendium of all of the official guidelines and recommendations published by the US Centers for Disease Control and Prevention (CDC) for the prevention of diseases, injuries, and disabilities. 


This compendium was developed to allow public health practitioners and others to quickly access the full set of CDC's guidelines from a single point, regardless of where they were originally published. This database was developed with financial support from the Information Network for Public Health Officials project. Select About the CDC Prevention Guidelines Database for more information.


How do these guidelines impact your state or territory? Please contact your state or territorial public health director .

To proceed, choose one of the following:

CDC Prevention Guidelines Topic Selection List

CDC Prevention Guidelines Select by Title (sorted by date)

CDC Prevention Guidelines Select by Title (sorted alphabetically)

About the CDC Prevention Guidelines

Directory of State and Territorial Public Health Directors


531 Center Road, Suite 2. West Seneca, NY 14224

Phone: 939-8899

[email protected]

phoenixrisingsleepmedicine.com


We do home sleep studies, portable equipment, very easy to use. 

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Efforts to minimize the side effects of CPAP therapy should be made in order to enhance the quality of patients’ lives and to increase the likelihood of good therapeutic compliance

Nasal continuous positive airway pressure (nCPAP) therapy for obstructive sleep apnea (OSA) was first described in 1981 by Sullivan and colleagues.1 Since then, CPAP is the treatment of choice for the majority of patients with OSA. Several mechanisms have been proposed to account for the benefit of nCPAP therapy such as the positive airway pressure acting as an “airway splint” and keeping the collapsible area of upper airway patent; nCPAP may maintain upper airway patency by a reflex mediated via the increase in end-expiratory lung volume. However, there is evidence against a reflex-mediated reduction in upper airway resistance. NCPAP has been shown to depress electromyographic activity of the upper airway dilator muscles,2,3 and lung volume dependence of pharyngeal cross-sectional area in patients with OSA has been reported.4 A direct relationship between lung volume and upper airway patency may be due to traction created on mediastinal and upper airway structures5,6; however, this effect plays a minor role in variation of upper airway resistance or patency with lung volume.7 CPAP eliminates OSA whereas continuous negative extrathoracic pressure does not eliminate apnea with comparable augmentation of lung volume.8 Hence, benefit of nCPAP is due to positive pharyngeal pressure.

NCPAP Compliance

After a CPAP titration study,9 the initial acceptance rate by patients is 70% to 80%. Most patients report a subjective sensation of well-being, decrease in daytime sleepiness, increased alertness, relief of morning headaches, decreased nocturnal awakenings, and decreased irritability. Reduced daytime sleepiness has been reported just after 1 night of nCPAP therapy.10 Individuals who derive no subjective benefit from such a trial are poor candidates for home therapy with CPAP and are likely to exhibit lower compliance rates.9 About 90% of OSA patients will adhere to long-term CPAP.9 Patients abandoning CPAP do so during the first few months of therapy.9 Lower acceptance and compliance rates have been reported in North America as compared to Europe.9 The American Thoracic Society reported overall compliance rates of 50%.11

CPAP therapy is associated with some side effects related to the patient-device interface. These include skin abrasion or rash, conjunctivitis from air leak, and ulceration of the bridge of the nose12; sensation of high airflow or pressure, chest discomfort, aerophagia, sinus discomfort, smothering sensation, insomnia, rhinorrhea, nasal congestion or dryness, epistaxis, and, rarely, pneumothorax, pneumomediastinum, or pneumoencephalos13-15; the device is too cumbersome and inconvenient and interferes with the patient’s lifestyle; spousal intolerance (one patient’s wife said, “That machine has taken my husband away and I hate it”); and indefinite or lifetime use of CPAP.

Several studies have examined patient compliance with nCPAP therapy. Sullivan and coworkers16 reported the initiation of nCPAP therapy on 35 of 50 patients with sleep apnea who had good compliance over a period of 3 to 30 months. Frith and Cant17 found that 72% of patients used nCPAP from 3 to 22 months. Nino-Murcia et al18 defined compliance as continued use of the device by 83% of patients. When compliance was defined as nightly or nearly nightly use, only 67% of patients were found to be compliant.18 However, none of these studies evaluated the number of hours the device was used per night. Sanders et al 19 demonstrated that 85% of patients undergoing a trial of nCPAP in the sleep laboratory were satisfactory candidates for home therapy if there was amelioration of sleep-disordered breathing by the device and patient willingness to use the device on a long-term basis. They defined compliance as nightly use of CPAP and patients were deemed compliant if they did not sleep without CPAP therapy more than 1 hour per night; 75% of patients sent home on therapy were compliant over 10.3±8 months (mean ±SD) of follow-up.19 Waldhorn et al15 found that 85% of patients tolerated a laboratory trial of nCPAP and 76% of patients sent home to use the device were still using it after 14.5±10.7 months. These studies determined patient compliance through questionnaire or interview data. When we reviewed the studies that used objective data, such as timers on the device to measure compliance, the mean duration of using the device was 5.1±2.6 hours per night and 40% of patients used the CPAP mask more than 6 hours per night.20 Fletcher and Luckett21 reported an average of 6 hours of CPAP use per night by patients.

Studies have suggested that compliance improves with increased severity of daytime sleepiness.15 The frequency or side effects of CPAP including initial apnea-hypopnea index, gender, weight, or prescribed level of CPAP did not appear to discriminate compliant groups of patients from those who were noncompliant.21 In long-term studies, the most consistent correlation of the daily use of CPAP was with objective measures of OSA severity at the time of diagnosis including the apnea-hypopnea index, the movement arousal index reflecting sleep fragmentation, or oxygen-hemoglobin saturation during sleep.9 In most studies, the multiple sleep latency test (MSLT) or scoring sleepiness at the time of diagnosis was not significantly correlated with the subsequent use of CPAP.9 Patients with low compliance did not have higher pressure.22

Improving Therapeutic Compliance

• Minimizing Side Effects of NCPAP—Poor mask fit can be addressed by trying different sizes of commercially available masks or by having a mask custom made. Nasal dryness can be treated with saline nasal spray at bedtime, a room vaporizer, or warm humidification added to the CPAP system. Nasal steroid sprays or ipratropium bromide spray can help with rhinorrhea.13,15 If a patient has chest discomfort or difficulty tolerating CPAP, bilevel positive airway pressure can help to reduce the expiratory pressure.23

• Nasal Prong System—This system is helpful in individuals suffering from claustrophobia, anxiety, or panic disorder.9

• Full Face Mask—Some individuals cannot tolerate nasal masks or prongs or are unable to keep their mouth closed during CPAP even with the use of a chin strap to permit adequate positive intrapharyngeal pressure. In such situations, using a full face mask should be considered. There is a potential risk of aspiration of gastric contents if the patient wearing a full face mask vomits. Patients should be instructed not to eat anything for at least 3 hours before applying the CPAP mask. Safety valves should be incorporated in the circuit close to the patient to facilitate inhalation of fresh air and to minimize dead space in the event of machine malfunction. An alarm must be present to signal power failure.

• Pressure Ramping—The pressure ramping feature of CPAP allows the adjustment of the rate of rise in delivered pressure over time from a negligible level to that required to maintain upper airway patency during sleep. This allows a window of opportunity for the patient initiating sleep. There are no published data available on the effectiveness of pressure ramping in improving patient compliance.24

• Therapeutic Use of Auto-CPAP—In an excellent review by Krieger,24 the therapeutic use of auto-CPAP was addressed. The rationale of auto-CPAP is that requirements in mask pressure are not constant, but vary in a given patient depending on several factors including alcohol, use of drugs, body position during sleep, sleep state, and nasal permeability as influenced by weather or allergic conditions (short term).24 The long-term factors include body weight, hormonal status, and sleep deprivation. This device, by adjusting instantaneously to the patient’s needs, is expected to correct breathing abnormalities better than fixed pressure CPAP.24 However, no published studies comparing the respiratory disturbance index (RDI) with auto-CPAP to RDI with fixed CPAP have demonstrated that the new technology was better than fixed CPAP in reducing RDI in short-term or long-term comparisons.25 Auto-CPAP offers no benefit over fixed CPAP in terms of the apnea-hypopnea index or other outcomes, and there was no difference in compliance with treatment between auto-CPAP and fixed CPAP.24

Bilevel Positive Airway Pressure

When using CPAP, patients may experience a smothering sensation while exhaling against positive pressure, chest wall discomfort, or nasal or sinus pressure. There is a potential risk of barotraumas in individuals with bullous emphysema, and alveolar hypoventilation may occur with increased expiratory pressure. Hence, CPAP pressure may need to be reduced to a minimal effective pressure. Upper airway resistance has been shown to increase during expiration despite the absence of negative intrapharyngeal pressure.26 Sanders and Kern23 suggest that splinting positive pressure in the upper airway during inspiration and expiration is necessary to eliminate apneic events. They propose that less pressure would be required to maintain upper airway patency during expiration than during inspiration.23 During expiration, inherent upper airway instability is the primary factor that favors upper airway collapse. CPAP provides equal pressure during inspiration and expiration. With bilevel positive airway pressure, adjustment of inspiratory positive airway pressure (IPAP) and expiratory positive airway pressure is possible. Sanders and Kern23 believe that in patients with OSA, bilevel positive airway pressure can deliver a sufficient level to prevent upper airway collapse during expiration. IPAP would augment airway patency to eliminate partial obstructions (hypopneas) with hypoxemia or arousals from sleep. With bilevel positive airway pressure, patients can determine their own inspiratory flow and frequency, and maintain a more physiologic breathing pattern; inspiratory-expiratory pressure cycling can be achieved even in the presence of mild to moderate air leaks.23 Patients find bilevel positive airway pressure to be more comfortable than CPAP (greater comfort associated with exhalation against lower pressure).23

Bilevel positive airway pressure is a therapeutic alternative for individuals who find CPAP uncomfortable or in individuals with severe bullous emphysema. Because average mask pressures are lower on bilevel positive airway pressure, air leakage, nasal congestion and rhinorrhea, chest discomfort, and risk of hypoventilation are reduced. However, it is not clear whether compliance with bilevel positive airway pressure is better than nCPAP. Bilevel positive airway pressure provides inspiratory pressure support and can be used to provide nocturnal ventilatory assistance in patients with neuromuscular diseases or chest wall disorders and associated OSA.23

The built-in time counter of the CPAP machine measures the cumulative time that the apparatus is turned on (machine run time).9 The time counter permits recognition of low rates of use. Here, early intervention helps to improve adherence and use of CPAP. Close follow-up can improve compliance.

In a randomized crossover study, patients with mild to moderate OSA were subjectively more satisfied with an oral appliance than with CPAP. This was despite the fact that CPAP was objectively more effective at correcting snoring, OSA, and excessive daytime sleepiness.27 Oral appliances are indicated for patients with moderate to severe OSA who are intolerant of or refuse treatment with nCPAP.28 There is a move to combine oral appliances and CPAP in new products. One uses an appliance instead of a mask to hold the hose delivering the pressurized air through nasal pillows directly into the nares.28 The aim is to eliminate the claustrophobia and air leaks associated with nCPAP (two common problems contributing to poor compliance). This combined device also eliminates the need for head gear to keep the mask in place. Another device delivers the pressured air directly into the oral cavity.28

Conclusion

The lack of subjective benefit from CPAP appears to be a major factor having detrimental influences on adherence and compliance.9

Every effort should be made to minimize the side effects of CPAP in order to enhance the quality of patients’ lives and to increase the likelihood of compliance. In my practice, I find that the severity of sleep apnea is directly proportional to the symptomatic improvement and consequently to compliance. Patients with more severe OSA are expected to derive more benefit from CPAP, and this probably accounts for the association between indices of OSA severity and CPAP acceptance and use.9 Patients who have family members or friends using CPAP are more acceptable to this mode of therapy for sleep apnea. In my opinion, educating patients plays a large part in their compliance with CPAP. This entails having a display of various masks including nasal pillows for patients with claustrophobia, Epworth sleepiness scoring, videos on sleep apnea and CPAP therapy, and visiting Web sites about sleep disorders. I also discuss the long-term cardiovascular risk factors associated with sleep apnea if it is not treated; they include an increased risk of heart attacks, cardiac arrhythmias, congestive heart failure, and strokes. The risk of sleep-related accidents is also discussed including the risk of car accidents while falling asleep at the wheel, which is 15 times higher. This information is reviewed at each patient’s appointment in the clinic for sleep disordered breathing. It is important that sleep specialists and the staff of the sleep center provide continuing educational resources and support for patients.

Taj M. Jiva, MD, is clinical assistant professor of medicine, State University of New York at Buffalo, and a pulmonologist, intensivist, and sleep specialist at Buffalo Medical Group PC.

References

1. Sullivan CE, Issa FG, Berthon-Jones M, et al. Reversal of obstructive sleep apnoea by continuous positive airway pressure applied through the nares. Lancet. 1981;1:862-865.

2. Strohl KP, Redline S. Nasal CPAP therapy, upper airway activation, and obstructive sleep apnea. Am Rev Respir Dis. 1986;

134:555-558.

3. Alex CG, Aronson RM, Onal E, et al. Effects of continuous positive airway pressure on upper airway and respiratory muscle activity. J Appl Physiol. 1987;62:2026-2030.

4. Hoffstein V, Zamel N, Phillipson EA. Lung volume dependence of pharyngeal cross-sectional area in patients with obstructive sleep apnea. Am Rev Respir Dis. 1984;

130:175-178.

5. Van de Graff WB. Thoracic influence on upper airway patency. J Appl Physiol. 1988;65:2124-2131.

6. Begle RL, Sadr S, Skatrud JB, et al. Effect of lung inflation on pulmonary resistance during NREM sleep. Am Rev Respir Dis. 1990;141:854-860.

7. Series F, Cormier Y, Desmueles M. Influence of passive changes of lung volume on upper airways. J Appl Physiol. 1990;

68:2159-2164.

8. Abbey NC, Cooper KR, Kwentus JA. Benefit of nasal CPAP in obstructive sleep apnea is due to positive pharyngeal pressure. Sleep. 1989;12:420-422.

9. Collard PH, Pieters TH, Aubert G, Delguste P, Rodenstein DO. Compliance with nasal CPAP in obstructive sleep apnea patients. Sleep Medicine Reviews. 1997;1:33-44.

10. Rajagopal KR, Bennett LL, Dillard TA, et al. Overnight nasal CPAP improves hypersomnolence in sleep apnea. Chest. 1986;90:172-176.

11. American Thoracic Society. Indications and standards for use of nasal continuous positive airway pressure (CPAP) in sleep apnea syndromes. Am J Respir Crit Care Med. 1994;150:1738-1745.

12. Stauffer JL, Fayter NA, McClure BJ. Conjunctivitis from nasal CPAP apparatus. Chest. 1984;86:802.

13. Strumpf DA, Harrop P, Dobbin J, et al. Massive epistaxis from nasal CPAP therapy. Chest. 1989;95:1141.

14. Jarjour NN, Wilson P. Pneumocephalus associated with nasal continuous positive airway pressure in a patient with sleep apnea syndrome. Chest. 1989;96:1425-1426.

15. Waldhorn RE, Herrick TW, Nguyen MC, O’Donnell AE, Sodero J, Potolicchio SJ. Long-term compliance with nasal continuous positive airway pressure therapy of obstructive sleep apnea. Chest. 1990;97:33-38.

16. Sullivan CE, Issa FG, Berthon-Jones M, et al. Home treatment of obstructive sleep apnoea with continuous positive airway pressure applied through a nose mask. Bull Eur Physiopathol Respir. 1984;20:49-54

17. Frith RW, Cant BR. Severe obstructive sleep apnea treated with long term nasal continuous positive airway pressure. Thorax. 1985;40:45-50.

18. Nino-Murcia G, McCann CC, Bliwise DL, et al. Compliance and side effects in sleep apnea patients treated with continuous positive airway pressure. West J Med. 1989;150:165-169.

19. Sanders MH, Gruendl CA, Rogers RM. Patient compliance with nasal CPAP therapy for sleep apnea. Chest. 1986;90:330-333.

20. ANTADIR. A multicenter survey of long term compliance with nasal CPAP treatment in patients with obstructive sleep apnea syndrome. Am Rev Respir Dis. 1990;

141:A863.

21. Fletcher EC, Luckett RA. The effect of positive reinforcement on hourly compliance in continuous positive airway pressure users with obstructive sleep apnea. Am Rev Resp Dis. 1991;143:936-941.

22. Kribbs NB, Pack AI, Kline LR, et al. Objective measurement of patterns of nasal CPAP use by patients with obstructive sleep apnea. Am Rev Respir Dis. 1993;147:887-895.

23. Sanders MH, Kern N. Obstructive sleep apnea treated by independently adjusted inspiratory and expiratory positive airway pressures via nasal mask. Physiologic and clinical implications. Chest. 1990;98:317-324.

24. Krieger J. Therapeutic use of auto-CPAP. Sleep Medicine Reviews. 1999;3:159-174.

25. Konermann M, Sanner BM, Vyleta M, et al. Use of conventional and self-adjusting nasal continuous positive airway pressure for treatment of severe obstructive sleep apnea syndrome: a comparative study. Chest. 1998;113:714-718.

26. Smith PL, Wise RA, Gold AR, et al. Upper airway pressure-flow relationships in obstructive sleep apnea. J Appl Physiol. 1988;64:789-795.

27. Ferguson KA, Onu T, Lowe AA, et al. A randomized crossover study of an oral appliance vs nasal-continuous positive pressure in the treatment of mild-moderate obstructive sleep apnea. Chest. 1996;

109:1269-1275.

28. Cartwright R. What’s new in oral appliances for snoring and sleep apnea: an update. Sleep Medicine Reviews. 2001;5:25-32.


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Comparative Guideline Tables

Comparative Guideline Tables are succinct summaries of recommendations from a variety of US and international organizations regarding controversial topics in screening, prevention, and management.

Aspirin for Primary Prevention

Breast Cancer Screening

Calcium and Vitamin D for Primary Prevention of Fractures

Lipid Screening in Adults

Nonoccupational Postexposure Prophylaxis (nPEP) for HIV

Preexposure Prophylaxis (PrEP) for HIV

Screening for Diabetes

Screening for Hepatitis C Virus

Screening for HIV

Screening for Osteoporosis

Screening for Prostate Cancer

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