"Sleep in Hospitalized Patients" Wissam Mansour (05.26.2021)

June 03, 2021

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00:02And Sam, just so you're aware,
00:05you're going to get these little popups that,
00:07say, admit so and so, and you can
00:09ignore them and Debbie and I was good.
00:16R. Alright guys,
00:19I think we're going to get started.
00:22Welcome, my name is Lauren Tobias
00:23and I want to welcome you to rail
00:26Speed seminar this afternoon.
00:27I have a few announcements before
00:30I introduce today's speaker.
00:31Please take a moment to make sure
00:33that you are muted in order to
00:35get CME credit for attendance,
00:37please see the chat room for instructions.
00:39You can chat.
00:40You can text the unique ID anytime
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00:48If you have any questions
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01:03And finally,
01:04you can share our announcements
01:06for Electro series with anyone
01:07who you think might be interested,
01:09or contact Debbie Lovejoy directly
01:11to be added to the list.
01:13I also want to let everybody know this
01:16is our last seminar for this academic year.
01:19I think we're going to be going
01:21out with a wonderful talk today.
01:23We are going to resume next year
01:27and the first week in September
01:30with a talk by Chandra Jackson.
01:33Conjured Jackson on sleep.
01:36This on health.
01:37Disparities in Sleep Medicine,
01:38which I think is really going to
01:40be a fantastic talk and we will be
01:43sending out the full schedule for
01:45the conference in August and then.
01:47Also, this is my last time leading this.
01:50It's going to be taken over by Janet
01:53Hilbert for the next academic year and
01:55I'm thrilled that she's going to be doing.
01:58I'm sure a fantastic job
02:00putting together speakers,
02:01so if anyone has any ideas for talks
02:03or topics that they're interested in
02:05seeing on the agenda for next year,
02:07you can feel free to reach
02:08out to Janet for that.
02:09So I'm going to turn it over to
02:11Melissa can air it to introduce
02:13our speaker for this afternoon.
02:15Thanks Lauren Lauren.
02:17Thank you for all that you've done for this.
02:20I want to call it state sleep,
02:22but the sleep seminar it's been just
02:24this year and in the past several
02:26years since you've taken over,
02:28it's been such a rich seminar
02:30series and so much appreciation
02:32that I know many other people feel.
02:35And so then it is also my pleasure today
02:37to introduce Doctor Wissam, a Sir.
02:39We have had the delight of having him
02:42as a sleep fellow this year at Yale and
02:44are so proud of all that he's achieved.
02:47Doctor Mansour came initially
02:48went to medical school in Beirut,
02:51Lebanon at the Lebanese University.
02:53He was a diagnostic radiology resident,
02:55so he's got some skills there.
02:57If you ever if you ever need them,
02:58he then came to the state
03:01and internal medicine,
03:02pulmonary critical care.
03:04Anne was pulmonary critical care
03:06chief fellow at the Zucker School
03:08of Medicine and Staten Island.
03:09The Northwell Health Center,
03:11and then we were delighted truly to
03:15recruit him asleep fellow this year.
03:18During his other fellowship in his residency,
03:21he won many awards,
03:22including Service Excellence Award,
03:24fellow Teacher of the Year.
03:25I know it's no surprise to
03:27me looking over your CV,
03:28knowing the wonderful job you've done this,
03:30you're teaching and taking care of patients.
03:34It also has been my delight this year to
03:36work with Sam on his research project.
03:38He really came up with the project
03:39and let it on his own and I was
03:42just there for support and I think
03:43a reflection of that quality is
03:45that it's been selected for an oral
03:47presentation at sleep and I can't
03:48wait to hear that talk as well.
03:49So without further ado and a great deal
03:51of thanks for a great year together,
03:53I look forward to this talk on
03:55sleep in hospitalised patients.
03:59Thank you, thank you Doctor
04:01ignore for the kind introduction.
04:02So good afternoon everyone.
04:06My topic today or my goal today
04:08is to give you an overview about
04:11sleep in hospitalized patients. R.
04:13I have no disclosure related to this talk.
04:18And this is just a reminder about
04:21texting the ID number below.
04:23If you would like to receive CME credit
04:26for this talk and Debbie will be putting
04:28those numbers also in the chat box.
04:33Throughout my talk,
04:35I plan to go over sleep disturbances
04:38in hospitalized patients discussing
04:41the types of these disturbances.
04:44Have an overview of what kind of
04:47health effects these disturbances may
04:49have go over certain factors that
04:53may affect sleep in the hospital.
04:56But giving an overview about certain
04:58tools that we have available to
05:00measure sleep in the hospital and
05:02finally concluding with possible
05:04intervention that we can use to
05:06help our patients sleep better.
05:09So I'll start us off with a case.
05:11Our patient is a 75 year old male who
05:14presents to the emergency room at 10:00
05:16PM for a three day history of fever,
05:19lethargy, cough and shortness of breath.
05:22He had a past medical history
05:24that was significant for asthma,
05:25hypertension, A-fib, and stroke.
05:29In the Ed, the patient was placed
05:32in the critical care section.
05:34Vitals every 15 minutes.
05:36He was started on some Ivy fluids
05:38for borderline blood pressure,
05:40he required oxygen support
05:42via high flow nasal cannula.
05:44He was given nabs antibiotics.
05:47Some blood work was sent and
05:49RVP was sent and xrays world.
05:53To Fast forward his care six hours
05:56later after after the easy work up,
05:59he was sent to the ICU with a
06:01diagnosis of sepsis and acute
06:03hypoxic respiratory failure.
06:04Secondary to a community acquired pneumonia.
06:07He was physically in the
06:09ICU at around 4:00 AM.
06:11After he was transferred,
06:12he had an initial assessment
06:14by the nursing staff.
06:16The overnight house staff came
06:18in and did their HMP at 5:00 AM.
06:21Phlebotomy came through blood
06:235:30 in morning X-ray that
06:24routine morning X ray and I see
06:26you was done and the 6:00 AM his
06:28scheduled nap treatment was given.
06:32So at 7:00 AM, Brown started in
06:36the ICU and the team went into
06:38the room to check on the patient
06:41and ask him how his night was.
06:44I'm just giving this case and I know
06:46a lot of what was done is important
06:49to provide patients with timely care.
06:51However, I wanted to show you some
06:53times where our patients might start
06:55off if we only take a look at their
06:59homeostatic and sleep deprivation.
07:00So in that morning the patient already
07:03started with this significantly
07:05high amount of sleep deprivation
07:07with a lot of sleep pressure.
07:12So the sleep disturbances
07:13in the hospital can be.
07:17Gross weight classified
07:19into three categories.
07:20Poor sleep quality,
07:22reduced sleep quantity and
07:25circadian misalignment.
07:30Her sleep quality was tested
07:32in both hospital wards and ICU
07:35and the largest study was done.
07:37The Netherlands,
07:38looking at around 1500 patients,
07:40and this was a subjective consensus
07:43sleep diary that was given to the
07:46patient so that they report their own.
07:49Subjective feeling of how their
07:51sleep was and they compared it
07:53to how their sleep was 3030
07:55days ago prior to admission.
07:58It did show that patients felt that their
08:01sleep latency was longer in the hospital.
08:04They had longer periods of wake after sleep.
08:06Answered, they had a total reduction
08:09in the total sleep time and the
08:11reduction in sleep efficiency.
08:15ICU studies had more objective data present.
08:20And they usually were done in
08:22a small group of patients where
08:25PSG's were performed and looking at
08:28hypno grams from from the patients,
08:31the top hypnogram is that of a normal adult
08:35showing sleep phases which are in Gray.
08:40Interrupted with short periods of
08:44wakefulness, those are in white,
08:45and if you compare it to the four
08:47patients that are below that,
08:49you can see the significant increase
08:51in number of arousers our ICU patients
08:54have the decreased efficiency in sleep,
08:56the increased N1 and N2 sleep,
08:59and almost complete absence of
09:01N3 and REM sleep in the ICU.
09:06In terms of sleep quantity,
09:09there has been few studies done in
09:11the medical words using actigraphy
09:14for patients for admitted patients,
09:16and it did show that the average in
09:19hospital total sleep time was around one
09:22hour less than that reported at home,
09:24suggesting a limit.
09:26A limitation in the quantity
09:28of sleep in medical words.
09:31As for the ICU.
09:33No, studies were slightly more objective.
09:36Looking at PSG data and if you
09:39look at this example of five ICU
09:42patients and you see their sleep,
09:45which is shaded in black,
09:47you can see that they were sleeping
09:49all over the 24 hour period.
09:52So despite not having adequate
09:54quantity of sleep during the night,
09:56if we take the whole 24 hour,
09:59maybe their sleep quantity is not.
10:00That is not that bad and this leads
10:03us to the idea that maybe ICU patients
10:07are more qualitatively sleep deprived
10:10rather than quantitatively sleep deprived.
10:14They can get this into consideration.
10:16I'm going to move to the third
10:19important sleep disruption and
10:22it's circadian misalignment.
10:24Two studies have been put forth to
10:26look whether or not our ICU patients
10:28do suffer from circadian misalignment.
10:30Looking at the main markers
10:33of circadian rhythm,
10:35which are melatonin and core
10:38body temperature?
10:39The first study looked at 13 ICU
10:42patients and they measured their
10:44melatonin levels every four hours.
10:46This graph that you see shows
10:50the bars of which we think those
10:53patients should have slept 2 hours
10:56after their melatonin peak.
10:58And that is compared to the black bar.
11:03Limited with with with their
11:05two blue lines showing,
11:07where would they ideally have
11:10slap between 7 between 11:00 PM
11:13and 7:00 in the morning?
11:15And as you can see,
11:16most patients had relatively
11:18advanced circadian rhythm and
11:20two patients had more.
11:28I'm sorry I had a more advance to them and
11:30other patients had them or delate delate.
11:35Looking at core body temperature,
11:37similar findings were noted and that
11:41triangles represent each patient
11:44core body temperature during the
11:45study and it shows you that the core
11:48body temperature was distributed
11:50along the whole 24 hours in the ICU.
11:53Patients, rather than being where
11:55most healthy normal subjects would be
11:58between 4:30 in the morning and 6:45.
12:03So now that we we have proof
12:05that our patients in the ICU are
12:08or in the hospital in general,
12:09I'll sleep deprived.
12:10It's important to look at what are the
12:14health effects of these sleep disturbances?
12:16Most available studies in the
12:18in this in this area.
12:21Actually looked at healthy subjects
12:23who were put under sleep deprivation
12:26or sleep restriction protocol,
12:28so we don't really have a lot of
12:30studies of patients who were sick
12:32who were then sleep deprived and
12:34looking how that organ systems react.
12:36That being said,
12:37you can and and as we would imagine,
12:41the health effects of short term sleep
12:44deprivation involves multiple organs,
12:46and I'm going to go through a few
12:49interesting studies in each organ system.
12:53We all know that BI directional relationship
12:56between like immunity and sleep deprivation.
13:02And a lot of reports have come forth
13:04noting that sleep deprivation for
13:0724 hours leads to a significant
13:09increase in neutrophil count and
13:12increase in their innate immunity
13:14was interesting about this study.
13:16Is they looked at the subpopulation
13:18of those neutrophils?
13:19And they even looked at the function
13:22of those neutrophils and how quickly
13:24they went into a respiratory burst.
13:26Looking at the graph,
13:28you can see that the neutrophils
13:30in patients who were totally sleep
13:32deprived noted in the black line.
13:34Had a much lower intensity of
13:38respiratory burst compared to that
13:41of patients who had normal sleep.
13:44And this leads us to the idea
13:46that maybe this increase in the
13:48inflammatory response after sleep
13:50deprivation is actually ineffective,
13:53and those neutrophils in hospital patients
13:55are not really going to do their job.
14:01Probably the most important neuro
14:04psychological effect that's been studied
14:07in the ICU or in the hospital has
14:09been delirium given its association
14:11with increased length of stay.
14:13Long term cognitive impairment
14:15increased one year mortality.
14:18A lot of researchers have looked
14:21into the pathophysiology of delirium
14:23and try to link it with sleep.
14:26Now it's important to note that
14:28sleep deprivation and delirium
14:29do share a lot of their clinical.
14:31An physiologic presentation of patients,
14:35so it does make sense for us
14:37to think about it.
14:38What's more interesting is
14:39that if we look at some of the
14:42proposed mechanisms for delirium,
14:44we can see that most 2 popular
14:48hypothesis are an imbalance
14:50in the neuro transmitters,
14:53where patients with the Lilium
14:54are thought to have a reduction.
14:56Reduction Institute choline
14:58and then increasing dopamine.
15:01And this also may happen to
15:03patients with sleep disturbances.
15:05And the other interesting theory was
15:08an abnormal tryptophan metabolism,
15:10where patients who had hyperactive
15:12delirium were found to have very
15:14high levels of melatonin,
15:16as opposed to patients hyperactive
15:18delirium who were found to have
15:20very low levels of melatonin.
15:22So some authors suggested that
15:25abnormal tryptophan metabolism
15:27favoring either multiple metatone
15:30production order production of DMT.
15:33Is actually what leads to
15:35delirium in our patients.
15:36And we all know how melatonin is linked
15:39to circadian rhythm and sleep in general.
15:44In terms of studies done on lung function,
15:48again, most of these studies
15:49were done on healthy patients,
15:51but it did show that sleep deprivation
15:53for even healthy patients results the
15:56next day in a blunted ventilatory
15:58response to hypoxia and hypercapnia.
16:01And impaired respiratory muscle endurance
16:03and a decrease in the junior clauses.
16:06Respons hinting towards increase in the
16:10upper airway resistance studies in COPD.
16:13Patients have shown that sleep deprivation
16:15would lead to reduced FEV one.
16:17And a study that was done in the
16:20hospital for CPD patients in acute
16:23respiratory failure showed that
16:25those who had poor sleep.
16:27And the hospital had a higher
16:29risk of progressing to needing
16:31mechanical ventilation.
16:37In terms of the cardiovascular impact,
16:40we know that sleep deprivation,
16:41even short term,
16:43results in increases in blood pressure.
16:45What is interesting and this
16:47data was provided to us mostly
16:50in postoperative patients.
16:52Is that as you see on the
16:54program to your left,
16:55a typical pre operative night for patients
16:58would have an almost normal hypnogram.
17:01With an acceptable amount of friends,
17:03sleep in it.
17:05On the operative night that patient had
17:08PSG done and it showed almost complete
17:10absence of N3 sleep or REM sleep.
17:13What was more interesting is
17:15that on the third on day three
17:18post up looking at their PSG,
17:20you can see that they go back
17:22to a almost normal pattern,
17:24but with a significant increase in the
17:27amount of RAM those patients experience.
17:30Now looking at one patient and
17:32what happens during the REM sleep,
17:34you can see to write the significant
17:37hard date variability during
17:39that period and the hypoxemia,
17:41especially in vulnerable patients.
17:44I would think that we might see a
17:47similar pattern in patients who
17:49are downgraded from the ICU or
17:51who have been recently extubated
17:53with sedation being stopped.
17:58So now looking at the factors that
18:01may influence sleep in the hospital,
18:04and as you can see there are multiple
18:06they interact with each other and you
18:09can list them into 2 broad categories.
18:12Environmental factors such as sound light,
18:16certain circadian cues,
18:17as more patient related and illness
18:20specific factors such as bedside
18:22care and the illness itself.
18:24With all the treatment that that comes with.
18:30I will start with discussing
18:32some of the circadian cues.
18:36To understand better how a change
18:38in the pattern of circadian cues
18:40may influence our patients,
18:42one should understand this Akkadian
18:44rhythm at the cellular level.
18:46Without going into much of details,
18:48our peripheral cells do
18:50use transcription factors,
18:52which are female and cloud.
18:54To transcribe proteins which are
18:57poor and cry, and those proteins
19:01do suppress their own expression.
19:03So after some time they go
19:05back into the nucleus,
19:06they bind to clock and bmal.
19:09Rendering them ineffective and
19:12hence their production will start.
19:15After some time those proteins
19:16get decorated by email and clock
19:19or up and ready again and they
19:21start producing these proteins.
19:25This cellular cycle gets a lot of influence
19:28from the outside and this is how we
19:31maintain in trainment with the environment.
19:34Light for example, and it's probably
19:36the most important slide paper in
19:39trains clocks, cellular clocks in
19:41the suprachiasmatic nucleus.
19:43And those neurons send a neurologic or
19:47a chemical signals to other cells in
19:50the body to keep them in in the rhythm.
19:53Other rhythmic and training cues are
19:56also present, maybe not as strong,
19:59but those include times of
20:02feeding changes in temperature,
20:05sleep wake schedules, and exercise.
20:09Why do we think this is important?
20:11Well, we all know that cells have a diurnal
20:14variability in terms of their function.
20:16And the changes of circadian gene
20:20expression well dictate what kind of
20:22genes the cell will express during
20:25that specific part of the day,
20:27and it will also dictate cellular Physiology.
20:32So while our most talked about circadian
20:36disruption would be that of sleep wake cycle.
20:41It is important to note that.
20:46As I gave it is also have a direct influence
20:50on the function of organs and cells.
20:53And that this arrangement of these
20:56affective side capers may lead mainly
20:59to a complete desynchronization
21:01between our central master clock
21:04and our peripheral cells and organs.
21:07Leading each organ functioning on its own
21:10time and having different expressions.
21:15So going going a little bit deeper
21:18into their cues, and as I mentioned,
21:20light is probably the most important
21:22slide paper data from hospitals,
21:24whether words or I see you have
21:27shown a similar pattern where
21:29patients are exposed to a relatively
21:32dim light throughout the day.
21:34And an acceptably dim light
21:36throughout the night. However,
21:38this light is interrupted by peaks of life,
21:42and this is just an example of office
21:45study that was done in the ICU,
21:47and you can see longer than black,
21:50the median of light exposure levels
21:54and the interquartile range in Gray,
21:57and what's important to note is that the
22:00light during the night was acceptably them.
22:03However, during the day and at around.
22:06Between 9:00 AM and 11:00,
22:07which was the peak exposure that
22:10light did not go above 140 lots.
22:13Just to put that into perspective
22:16of what we experienced,
22:18the sunny day is 30,000 lux and
22:21office slide that has no windows
22:23would be 500 lux O our hospital
22:25patients are significantly under
22:27exposed to light during the day.
22:32What I found also interesting
22:34is that the light patterns in
22:36the hospital don't really differ
22:39between morning and night.
22:40So a study looking at the
22:42difference of certain habits,
22:43such as using lights in the room,
22:46leaving the TV on,
22:47having the window shade clothes
22:49was really not significantly
22:51different to morning,
22:52noon or night time.
22:56So back to our patient.
22:59That afternoon the patient decompensated.
23:02He required intubation,
23:04mechanical ventilation.
23:05He was started on sedation
23:07restrained and the gastric tube
23:10was placed for continuous feeds.
23:12Just to give you guys an idea,
23:14this was the light profile for
23:17the ICU patient between 8:00
23:19PM and 8:00 in the morning,
23:21and as you can see the light level
23:23exposure has been pretty them
23:25throughout the night with a peak
23:27and light exposure at around 3:00
23:29AM to 4:00 AM and this correlated
23:31to the patient undergoing a path.
23:36Another important circadian
23:38queue is the timing of meals.
23:41And it is important for us
23:42to know that the GI system,
23:44including the anchors and liver
23:46function in a in a circadian rhythm and
23:50exposing patients to continuous feeds
23:52like we usually do in the ICU or small
23:56fields with an additional feed at 2:00 AM,
23:59which is also a common
24:01arrangement in the ICU.
24:02Well, the result in a significant
24:04disruption in that cycle and
24:06put patients into complete
24:08distinction between their central
24:10rhythm and the peripheral.
24:11Peripheral cellular.
24:15So, after discussing circadian cues,
24:18I want to move on to discuss another
24:20important disruptive environmental
24:21factor in the hospital, which is.
24:24And sound can come from
24:26many different sources,
24:28most commonly reported or alarms,
24:31and how staff conversation in
24:33addition to some outside knows such
24:35as street cars or health partners.
24:41WHO sound recommendation for
24:43someone to have good sleep?
24:46Is to have a continuous background noise
24:49of less than 30 a weighted decibels?
24:52And to have noise events not higher than 45,
24:57a weighted decibels and the definition of
24:59noise events may value from study to study,
25:02but it's basically an increase in
25:05the noise from the from the back.
25:09Looking at what we do in our hospital,
25:12John Hopkins did an extensive study looking
25:15at what happens on medical wards and
25:18what's the sound level in patients rooms.
25:21As you can see in this graph,
25:24plotting the different rooms on
25:26the X axis and the level of sound
25:29exposure on the Y axis.
25:31You can see that the average sun exposure,
25:35which is plotted and straight
25:37black lines and squares.
25:39Was between 50 and 60 decibels.
25:43The red line represents the peak.
25:47I allowed threshold for The Who and
25:51the blue line represents the background
25:53threshold and you can see that our numbers
25:56are significantly higher than that.
26:00ICU studies were no different
26:02against showing a significantly
26:03high level of sound exposure.
26:08What was also interesting in this study is
26:10that they looked at sound peaks that occur,
26:13and I see an environment and these were,
26:15by the way sensors placed next to
26:17patients heads. So that's exactly
26:18what the patient is heating.
26:20And you can see that noise
26:23peaks that exceed 85 decibels.
26:27Were plotted in bars in Gray,
26:29and the noise peaks that exceeded
26:32100 decibels were plotted,
26:34and bars in black.
26:36And throughout the whole day,
26:39you can see a significantly
26:40high number of noise events,
26:42but more interestingly,
26:43if you look in the middle of the graph,
26:45which is the period between probably
26:4712:00 AM to 6:00 in the morning,
26:50you can see that patients had
26:52at least at least five noise
26:55events per hour of their sleep.
26:59Just to put this into perspective
27:01again and comparing it to loudness
27:04chart so the average background in our
27:07hospital units is similar to that of
27:09someone sleeping next to a dishwasher
27:12or someone sleeping next to someone
27:14who's having a conversation with him.
27:17Looking at the peaks,
27:18it's similar to someone who's
27:20sleeping on a highway next to
27:22traffic or even in the subway.
27:28Another important factor of sound
27:30in addition to the idea of peaks
27:33probably being more disruptive than
27:35background is the source of the sound.
27:38And some work was done in to that end.
27:42And they looked at different,
27:44so this work was done again on healthy
27:48subjects and they were subjected.
27:51Over the night of sleep,
27:52two different sounds that people may
27:54experience in the ICU and different sounds.
27:57And they looked at that e.g and determine
28:00whether or not the patient had an arousal
28:02in response to that sound and at what
28:05level that we even had an arousal.
28:08And on the graph on top you can
28:10see the different colors represent
28:13a different sound source.
28:15And when the when the color is
28:19completely completely shaded.
28:20This is when the patient had their houses,
28:23so you can see that different sound sources
28:26had different impact in terms of arousers,
28:28and they concluded that electronic sounds,
28:31such as alarms were actually more
28:33arousing to patients than other sounds,
28:36such as people talking.
28:41Again, going back to our patient,
28:43this was his sound exposure.
28:45During the night you can see that the
28:48average background noise was around 48,
28:51which is again higher
28:52than the recommendation.
28:54You can see multiple peaks and the
28:58average of the peaks was around 8/4 hour.
29:01And again, as a reminder,
29:02sound peaks are probably more
29:05associated with arousals from
29:06sleep than continuous backgrounds.
29:11So that moves us to the 4th
29:14component of the sleep disruptors,
29:16and this is bedside care.
29:20In a study looking at how much
29:23activity occurs in patients
29:25who 50 patients were sampled
29:28from the three different ICU's
29:31in a New Jersey hospital.
29:32And if you look at the bars,
29:35you can see that.
29:36From 7:00 AM to 6:00 in the morning,
29:39almost every hour the patient
29:41had an interaction with someone,
29:43and within one hour sometimes
29:45it happened 4 four times.
29:49Another interesting findings in those isues.
29:53And each bar from this represents
29:56a different different type of ISU,
29:57but it's probably consistent across all four.
30:01Was the timing of the path.
30:04So most of our patients received a bath
30:06at around 4:00 or five in the morning.
30:12Going back to our patient,
30:13this was the number of entrances
30:16and exits from his room.
30:18And as you can and this is from
30:198:00 PM to 8:00 in the morning,
30:21and as you can imagine,
30:23this number is significantly high,
30:25reaching 238 entries for one nine.
30:33Last but not least is the impact of the
30:36illness itself on the patients sleep,
30:39and that illness can can result
30:42in sleep disruption because of.
30:44Neurological involvement like brain damage,
30:47multi organ failure, pain,
30:48anxiety from the illness or it can
30:52result from disruption due to treatments
30:54such as using a mechanical ventilator,
30:58certain certain medications.
31:02Looking at the endless by itself,
31:04it's important to note that different
31:07illnesses may result in different impact
31:09in different impact on patients sleep.
31:12This study compared 11 ICU patients who
31:16had sepsis to 11 ICU patients who did
31:20not have substance and it looked at the
31:23influence of sepsis and inflammation on
31:25the expression of circadian rhythm genes.
31:29The sepsis patients were persisted on
31:32this figure in red and as you can see,
31:35the expression of the cry one
31:38protein was significantly decreased
31:40in patients who had sepsis.
31:44And it really lost its variation with time.
31:50Another study looked at injecting
31:53endotoxin to human healthy volunteers.
31:56Yes, this was IRB approve.
32:00And they looked at the expression of these
32:03circadian genes in their local sites.
32:05Following the injection of the endotoxin,
32:08as you can see to your left,
32:09there was a significant reduction in the
32:12expression of multiple circadian genes.
32:15And this reduction persisted
32:17for around 24 hours.
32:20But what was more interesting is
32:22that looking at the melatonin level,
32:24the melatonin secretion was not
32:27really impacted by this injection.
32:29And that's an important idea.
32:32To have us wonder whether or
32:34not impact on peripheral cells
32:36is different than the impact on
32:38the central circadian rhythm,
32:40and hence leading to an internal
32:44desynchronization between circadian rhythms.
32:48Another very important factor,
32:50but probably too wide for us
32:53to dive into during this talk,
32:55is the effect of medications we
32:57use in the hospital on sleep.
32:59I'm just putting this to show you to
33:02give you an idea of how much different
33:06medication classes can impact sleep,
33:08its architecture and quality.
33:13Now moving to available tools that may
33:15allow us to measure sleep in the hospital.
33:19PSG is probably the gold standard
33:21for sleep measurement, however,
33:23in the hospital setting it is
33:25a labor intensive procedure.
33:27It's pretty costly.
33:28It's very difficult to tolerate by
33:31patients for 24 hours specially,
33:34especially in non ICU patients
33:36who are active.
33:38And another important point is that the
33:40traditional scoring may be difficult.
33:42In critically.
33:43I'll patients who may lose K
33:45complexes spindles due to the illness
33:47or due to certain medications.
33:52Actigraphy has also been tried.
33:55It's an it has an acceptable correlation.
33:57PSG based on previous studies.
34:00It is of low cost.
34:02It could be used for multiple nights and
34:06it's very well tolerated by patients.
34:09The problem with actigraphy is
34:12that it may overestimate steam.
34:14And especially in patients who are
34:16inactive and I see patients who are
34:19sedated since activity is a major factor
34:21in the algorithm of these devices.
34:25And it doesn't really provide
34:27any sleep staging data.
34:31To make things even easier, some sleep
34:33questionnaires have been put forth,
34:35and the most commonly uses the
34:38Richard Scampbell Sleep Questionnaire.
34:40It was, it did have a
34:44content validity against PSG.
34:46In the relatively small study.
34:49But the questionnaire asks
34:51patients about their sleep depth,
34:53latency, number of awakenings.
34:55How much time it took them
34:57to go back to sleep?
34:59Their assessment of their sleep
35:01quality and whether or not there was an
35:05intervening factor disrupting their sleep.
35:07And one example of that was noise,
35:10and they give them a visual analog
35:12which is from zero to 10 or zero to 100,
35:15with 0 being the worst and 10 or
35:19100 being the best qualities.
35:24Now, now that we know the impact
35:27of these sleep disruptions,
35:28that type of these sleep disruptions
35:31some ways for us to evaluate how our
35:34patients in the hospital are sleeping.
35:36It's important to see whether or not.
35:39Interventions may help.
35:44Looking at our patient, for example,
35:46or a patient with an illness in general.
35:49There are certain factors that
35:50we cannot really run away from.
35:52Our patients need timely care.
35:55They need certain medications.
35:56Even though a lot of the stuff
35:59that we do can be adjusted chilly
36:01in the non emergent setting.
36:03But possibly the most Inter
36:06Venable point in all of those
36:08factors would be the environment.
36:13Some studies have looked at the use of
36:16bright light therapy during the day,
36:18and as I mentioned,
36:19light has a very very important role
36:23in maintaining circadian rhythm.
36:25And one of the initial pilot
36:27studies was done,
36:28or postoperative patients who
36:30were exposed to light for around
36:332 hours in the morning for three
36:36days after their surgery.
36:37And that resulted in decreased delirium.
36:42In their patients who were exposed
36:44to light compared to the control.
36:48In addition to that,
36:49few other studies have shown
36:51that bright light therapy
36:52during the day in the hospital.
36:55Would result in improvement
36:57and subjective sleep quality.
36:59Expose agitation episodes in
37:02mechanically ventilated patients and
37:04one study even showed a reduction
37:07in mortality in patients post AM I.
37:09And that study randomized compared
37:11patients who were placed in adult
37:14room versus those in a sunny room.
37:16However, this mortality benefit
37:18has not been reproduced.
37:22So how can we really?
37:23How can we intervene in our patients?
37:27It is important to realize that this
37:30is a multidisciplinary approach.
37:31And protocols should be put with a
37:34cluster care in mind from various
37:37staff members and providers.
37:40Controlling sounds would be the easiest.
37:44There has been suggestions of
37:47using tally alarms where nursing
37:49staff or providers can actually
37:52carry those tally alarms with them,
37:55and instead of the alarm beeping
37:56next to a patient like a mechanical
37:59ventilator patient who can do nothing,
38:01absolutely nothing about the
38:02alarm except waking up to it.
38:05Actually having the alarms beep
38:06next to the staff who will actually
38:09be able to respond to it.
38:11Providing daytime light has
38:13been showing some promise,
38:15not completely consistent across all studies,
38:18but it is showing some promise
38:20preventing overnight light exposure,
38:23specially from unnecessary procedures.
38:26Rescheduling certain routine
38:29patient care requirements.
38:31It's very important to
38:33reassure these patients,
38:34as we mentioned that anxiety and
38:36controlling their pain is a very
38:39important factor in reducing
38:40sleep disruption.
38:41Changing our nutrition strategies.
38:44And avoiding continuous meals and
38:46mobilizing patients as soon as possible.
38:52For that purpose,
38:52some work has been put forth,
38:54and this is some work done by the Yale team.
38:58And this is the evaluating the use
39:00of a nap time during the night
39:03or arrest time and the rest time
39:05was basically for four hours for
39:07ICU patients between 12:00 in the
39:09morning and four four in the morning.
39:11And what they basically did is they try
39:15to reschedule or unnecessary patient care.
39:18And a nurse was like the gatekeeper
39:21to make sure that this protocol is as
39:26well implemented for the patients.
39:29If you look at the impact of the protocol,
39:32those figures show the control
39:34subjects and squares and the patients
39:37one went protocols in circles.
39:40Looking to your left is.
39:44Is the number of entrances into the
39:47room before 12:00 AM and looking to
39:51your right is what happened after
39:5312:00 AM till 4:00 AM and you can
39:56see a significant reduction in the
39:59intervention group in the number
40:00of entrances into the room.
40:02A significant reduction in the
40:04background noise and more importantly a
40:07reduction in the number of sound peaks.
40:10During that, during that period of rest.
40:17Other hospitals have adopted promoting sleep
40:20hygiene and having a care bundle for it,
40:24in which all the hospital staff
40:27are involved in. So for example,
40:29physicians have a main role in avoiding
40:31unnecessary diagnostic studies,
40:33so maybe our patient did not need that
40:35repeat chest X ray early in the morning.
40:37Maybe his nebuliser could have been
40:40pushed a little bit. Avoidance of.
40:45Letting patients having anxiety.
40:47Communicating well with
40:50patients and reassuring them.
40:52The nursing staff has a vital role
40:55in terms of being gatekeepers for
40:57implementing the bundle and avoiding
41:00any non urgent bedside care such as
41:03the path that we noted in our patient.
41:07Respiratory therapists have a
41:09role in avoiding unnecessary
41:12suctioning during the night,
41:14and even though I didn't
41:15go into depth about it,
41:17but alerting and adjusting settings
41:20to avoid ventilator asynchrony is
41:23key in avoiding patients having sleep
41:25disruptions at night in the ICU.
41:28Pharmacists also have a role
41:31in changing ordering protocols.
41:34Nutrition have a major role in avoiding.
41:39It was two fields and maybe using a more
41:42daytime restricting feeding protocol.
41:44Physical therapy with early mobilization.
41:48Hospital administration with
41:49implementing certain policies.
41:51Maybe the alarm monitors may be
41:54increasing staffing during the
41:56day to allow for taking paths,
41:59increasing availability of other
42:01services such as trash pickup
42:03during the day instead of 4:00 AM.
42:08Avoiding any maintenance work overnight.
42:12And there's also a role for ancillary
42:15testing services may be increasing staffing
42:17during day shifts to avoid very early
42:20on need for phlebotomy or chest xrays.
42:26I wanna I wanna end with this code
42:29from Doctor Rhonda Ouch who was
42:32actually an ICU patient in 2017 and
42:37she wrote a book about her experience
42:40in the ICU and this is probably the
42:43most resonating take home message.
42:45So she said that the absence of even
42:48a full minute of silence combined
42:50with a constant pain made sleeping
42:52difficult for me every other moment.
42:55An alarm would sound.
42:56A monitor would be.
42:58There was near constant noise
43:00activity and the whole cold school
43:03called all over the PA system.
43:07With this I would like to end my talk.
43:09A big thanks to my mentor,
43:12doctor Melissa Kynar,
43:13who has guided me throughout this
43:15whole year and was kind enough to
43:18share her work with me and some
43:21of the slides I showed and big.
43:24Another big thank you to the Sleep
43:27Medicine team including faculty,
43:29staff and Michael Fellows for what
43:32was really an amazing guy right here.
43:35Thank you very much and if you guys
43:37have any questions please feel free.
43:44Thanks everyone, yes if you want to
43:46put questions in the chat or just
43:48unmute and ask, go right ahead.
44:07This is a in where I had a question that was
44:10a great presentation and really you know,
44:12great job in talking about all
44:14the basic science, Physiology.
44:16Everything kind of put into a very
44:20complicated hospitalization with a lot
44:22of different external factors going on.
44:24You know the one thing I kind of
44:26struggle with with this topic is you
44:28know what has been proven to kind of
44:31change patient centered outcomes I mean.
44:32We have a lot of theoretical
44:34evidence that you know these things
44:37could help and sleep deprivation.
44:39The harms of deprivation and and so forth,
44:41but hasn't there been any sort of evidence
44:44in the last few years or so that have
44:48looked at specific interventions on,
44:50you know, changing the environment,
44:52let's say in the ICU,
44:53where you know my main interest is and
44:55and can that really have a dramatic,
44:57heavy, significant impact
44:59on mortality length of stay?
45:02So we admission rates, etc.
45:05I know that there there's been some
45:07data looking in non ICU patients
45:08on heart failure and getting those
45:10patients diagnosed and getting
45:12them on PAP therapy and that could
45:14potentially reduce readmission rates.
45:15But have you?
45:16Have you seen anything that you
45:18know says by shadow of doubt?
45:20You know we should be doing this 'cause
45:22this is going to have a meaningful
45:23outcome and what are the future
45:25needs for the research in the field?
45:26So a lot of questions,
45:27but you could do your best.
45:29That's
45:30OK. Thank you doctor weird.
45:31So I think that. For now,
45:33just probably more experience in this topic,
45:37but from from what I was seeing is
45:39this is a pretty young field like most
45:42of the studies are very, very recent.
45:45There is this difficulty in it really
45:48assessing sleep in these patients,
45:51really assessing whether or not
45:53our interventions are helping,
45:55and most of the studies that we have have
45:58been pretty pretty down size too small.
46:01Sample size.
46:02Now that being said.
46:03One of the interventions which I felt
46:06was gaining a lot of popularity was
46:08bright light exposure during the day,
46:11even though it did not show this
46:13benefit in all patient groups.
46:16But it shows some trend towards
46:18decreasing delirium in our patients,
46:20and we know how delirium can
46:22impact those patients.
46:23It did show a trend tower patients
46:26having improved subjective
46:27sleep quality and reduction in
46:29hospital stay and length of stay.
46:33So there is this.
46:35Trend on,
46:36not sure about other data that was
46:38able to actually show that those
46:41sleep under high jeans or in app
46:43protocol would actually influence
46:46direct big outcomes like mortality.
46:49In our patients.
46:53So Sam, that was an absolutely
46:56brilliant, brilliant presentation.
46:59Did we learn anything from
47:02patients who were admitted to
47:04hospital with COVID about sleep?
47:08I I personally have not come
47:11across any study. You mean and
47:15during that hospitalization,
47:16right during their hospitalization?
47:18That's correct. Yeah
47:19yeah, I personally did not come across
47:22any study looking at the patterns of
47:25sleep in patients admitted for COVID.
47:27I'm not sure if anyone else did or
47:29would like to share that experience.
47:39I'll just say, anecdotally,
47:40it's hard to sleep with a high
47:42flow nasal cannula on 24/7,
47:44so for the patients that we
47:46see as pulmonary critical care,
47:49you know there seems to be a lot of sleep
47:51deprivation prolonged hospitalization.
47:53I imagine there's REM deprivation
47:55and those type of things,
47:56but that's a great question.
47:57Like, has anyone really looked at?
47:59You know, for these patients that are
48:00being in the hospital for a long time,
48:02especially with the high flow out?
48:03Jen and prolonged you know requirements,
48:07but yeah, they a lot of times
48:09they'll say that they're exhausted
48:10and they and they can't sleep.
48:12But I don't think we have at
48:14least any objective evidence.
48:16Yeah, and I think the other factor
48:18that might need to be looked at is the
48:21is interaction with family members.
48:25I mean obviously during Kovit,
48:26family members were seldom allowed
48:29to come and be next to the patient,
48:33and that's something that
48:34I'm guessing had a terrible,
48:36terrible effect on anxiety,
48:38stress, an inability to sleep.
48:49I agree, I am very intentionally not
48:53asking questions, but I would comment.
48:57To your question in I think Sam hit
48:59the nail on the head is that that
49:01what really limits the field asleep
49:03measurement an it's my continuous hope
49:05that these newer and better wearables
49:07that are getting ever smaller and ever
49:10more comfortable are going to sort of
49:11be a way forward eventually so that we
49:13can prove I have a very small study that
49:17was retrospective and has limitations.
49:20But loss of stage and two features
49:23was associated with death in ICU and
49:26generally speaking in that study also
49:28showed changes in length of stay.
49:30It's a very particular patient
49:32population that we looked at,
49:33but I think it's there.
49:34I just think it's the challenges in
49:37measuring and as Sam showed so nicely
49:39it's so complicated and so how do you?
49:42How do you pull one piece out of the web?
49:45Yeah.
49:49Alright, other questions.
49:55Hi, thank you, thank
49:57you for that great talk.
49:58This is Lori Schechter. I'm from
50:00Columbia University.
50:00It's a first time joining in on
50:03this session is really interesting.
50:04Appreciate being able to be here.
50:07Quick question
50:08for you mentioned briefly about some
50:09of the methodological
50:11limitations of using actigraphy.
50:13In patients to track sleep and
50:17I was wondering if you could
50:18just if you could just talk
50:19about that for another second and
50:22you know, aside from questionnaires,
50:26what would be some potential
50:29alternatives right now,
50:31aside from PSG as well. Sure,
50:34so that the limitation of actigraphy is
50:38mostly in hospital patients who are who
50:40lack a lot of activity during the day.
50:43So even though they're away if they're
50:45sitting in bed still, the acting
50:47actigraphy may report that as sleep.
50:51And more, especially in patients
50:53who are sedated in the ICU who are
50:57not really doing much of activity,
50:59and so actigraphy may overestimate
51:02sleep in those patients.
51:04It probably would have a better
51:06correlation in patients on the wards.
51:09Who are more active,
51:11leaving their room doing stuff?
51:13As for as far as other potential
51:16devices that we can use in the future,
51:19so I know doctor clout mentioned
51:21the variables.
51:22I saw only one study where they use the
51:25two and they try to compare it to PSG.
51:28It didn't have a great correlation and
51:31I'm sorry they didn't compare to PSG.
51:34They compared actually too subjective
51:36sleep and it had a moderate correlation
51:38with what the patients reported.
51:41Another possible thing that we may
51:43use in the future is the technology
51:46called old 3 issue product where
51:49they use a single DDG and then
51:51they kind of dissect that,
51:53EG into very tiny 3 second three
51:56second parts and they give you a number
51:58based on the activity that's going on,
52:01and that number correlates well
52:04with wakefulness or being asleep.
52:06This this may be easier to
52:09do compared to full montage,
52:11but this has not been studied
52:13in the inpatient setting.
52:14The data,
52:14the data that we have are all
52:16in the outpatient setting.
52:21Thank you.
52:34Alright, well that well thank you
52:35so much Sam that was wonderful.
52:37He represented the
52:39complexity of the challenges.
52:40The field really well and what
52:42a great way to end the year.
52:44For those of you who joined a little late,
52:46this is the final session of the year
52:47and so also a congratulations to
52:49Doctor Tobias for all the lecture.
52:51Wonderful lecture she put together this year.
52:56Thanks everybody, have a great
52:59summer. And I'll see you in
53:00the fall. Thank you. Bye bye.