By: Edward T. F. Wei PhD
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For example asthma symptoms fever , the section immediately below begins this process by discussing traditional government and own-source fnancing mechanisms in detail asthma treatment bird . Ultimately asthmatic bronchitis 37 , fnancing environmentor climate-related investments begins with the fnancial management of existing assets asthma symptoms rash . If these are well maintained and effciently utilized asthma research , additional investments may be postponed and even avoided. For example, introduction of water meters in Brisbane, Australia allowed users to manage their water consumption more effciently. This enabled reductions in average consumption down to 123 liters per day, making Brisbane residents some of the best water-savers in the developed world. More importantly, this signifcantly contributed to deferment of programmed capital investments totaling $3. In addition to managing and effciently utilizing existing assets, if appropriate, these can be leased out for management by a third party to produce cost savings, or possibly to generate a proft for reinvestment in new assets. Even with the best management of existing assets possible, new projects still require funding. Investment programs for this purpose should be based on sound asset planning that takes account of environmental, energy-effciency, and climate-change issues. Again, the foundation for this funding is own-source resources, which in Figure 7. The need for proper fnancial management is thus fundamental to obtaining fnancing for environment-related projects, and is an unavoidable step in obtaining it. Maximizing Own-Source Financing the amount of fnancing available to a particular project is based on the fnancial strength of the entity seeking it. In this regard, the old saying that “the less you need money, the more people want to give you” is applicable to obtaining fnancing for environment-related initiatives. Local governments and other subsovereign sponsors of urban environmental infrastructure are often their own worst enemies in that their willingness and capacity to collect even the revenue they are due is poor. Properties missing from the register, undervaluation of the properties that are included in it, lack of effective local government collection mechanisms, and informal payments made in lieu of tax collections all undermine the fscal health of project sponsors and deprive them of the means they need to leverage other forms of funding. Aside from collecting all mandated taxes effciently, the following are several additional areas in which cities may bolster fnancing1 • User charges that cover the full cost of services such as water and electricity. This includes the cost of providing supply and damage caused by usage, as well as the opportunity cost of taking the resource from other potential users, including the ecosystem. Financing Sustainable Cities 299 • Emission or effuent charges based on the “quality” or quantity of waste generated. This includes entitling an entity to treat its waste and sell its permit, or to not treat its waste and purchase additional permits suffcient to counterbalance the amount of pollution released. While numerous types of public sector funding are available for green investments, it is sound local-revenue performance that provides the basis for access to grants and other types of fnancing from higher levels of government. However, this is only true given the absence of perverse incentives, which effectively reward governments or agencies for poor performance. For example, a housing grant program that provides funds in proportion to the number of dilapidated dwellings in the public housing stock effectively encourages poor maintenance of such dwellings. Leveraging Private Sector Financing Project sponsors should explore the unbundling of commercially viable or contestable infrastructure components that can be fnanced by the private sector. This entails separating components that must be governmentfunded from those that the private sector might wish to undertake. For example, water treatment plants can be unbundled from the piped network that serves such water systems. Private sector participation must be supported by effective, independent regulation that mitigates the risks associated with a private entity being in a monopoly-provider role in the provision of basic services such as water and energy. The regulatory regime must contain provisions for a fair service price, sustainable service provision, and any distributional objectives. Contracts should clearly specify the funding for any public service obligation of the provider, such as lower prices for the poor to be provided through sustainable government transfers, tax-deductible cross-subsidies, or other means. This section lists the types of environment-related projects that might receive high priority for fnancing, and summarizes the key issues and risks associated with each type of project, including how revenue might be generated to service debt or provide a return to equity investment. Conversely, ridership projections for bus rapid transit systems typically overstate actual ridership. Energy, energy effciency, and industrial greening initiatives: • Project formulation and development processes are expensive, but are often recoverable. City greening: • As with drainage facilities, revenue streams for parks and other open spaces are sometimes limited. Urban agriculture: • Some cities such as Shanghai already obtain a signifcant share of their total food supply from their immediate hinterlands. District heating and cooling initiatives: • the energy cost for district heating and cooling and its reliability are potentially important issues, although effciencies can be achieved through planning and the use of cogeneration. Financing Sustainable Cities 303 Adaptation Investments: • It is often diffcult to justify capital costs for providing essentially the same service as previously, although the manner of provision is more climate-resilient than previously. Existing Subsovereign Systems for Environmental Infrastructure Finance Overall Context the practicalities of fnancing specifc investments, or changing the pattern of investments for addressing global environmental issues such as climate change require a clear understanding of the policy context in the country concerned. The latter sets country priorities, and thus the resources available both from the public and private sectors for fnancing such investments. Because they are rarely represented in the legislature, they cannot directly infuence government resource allocation or policies that determine resource allocation by other levels of government, utilities, households, or enterprises. Budgetary priority thus goes to investments that foster growth, which is defned in materialistic terms such as roads, ports, 304 Green Cities water supply facilities, and housing, which constitute the basic infrastructure that supports growth. If many citizens cannot access adequate housing and political awareness of this issue is great, a national or local government that diverts resources from low-income housing does so at its peril. A third issue compounding the “priority” problem is the size of the informal sector. Much larger portions of developing country economies are in the informal economic sector—up to 60% in some countries. Legislation, tax breaks, and standards do not heavily infuence enterprises that are not registered, that do not pay tax, and that have no concept of standards except as justifcations for bribes. A fourth issue compounding the “priority” problem is simply lack of capacity—technical, administrative, and, most particularly, fnancial. The (understandable) attitude is: “better to resolve immediate issues for which we have some capacity than to attempt to resolve issues for which have few resources. What this means for fnancing such investments is explored in the following sections. The Four Components of Sound Financing Systems Sound fnancing systems must comprise four components if green fnance is to be forthcoming. Furthermore, each of the following components helps overcome the impediments described above: 1) National fscal structures that provide incentives, both positive and negative, for pollution reduction, energy effciency, greenhouse gas 4 Because with money, you can usually get the technical and administrative inputs required. Potentially, such structures can address all of the above issues if well designed. Such structures are often fnancially and economically viable in the long run, but require signifcant up-front outlays to implement. A fnancing system that incorporates all four of the components above in a way that allows their benefcial interaction allows green issues to be addressed in a comprehensive way. One example of this is the Republic of Korea’s fnancing system that includes a Green Growth Initiative. This program targets both the demand and the supply side of green products and investments (respectively referred to as Green Consumer and Green Industry in Figure 7. These activities are supported by tax-revenuefunded green research-and-development funds that assist industry in developing the products, services, and infrastructure required for supporting a green economy. Under the program’s Green Government component, the government acts as a role model, a coordinator, and a standard-setter. While government can promote change by paying for key investments directly, the most effective method of promoting green growth, as depicted in the Republic of Korea system, is through leveraging private sector funding. The total amount of urban infrastructure (mainly environmental infrastructure) required each year in Asia is valued at an estimated $100 billion, while current annual urban environmental infrastructure investment is about $40 billion (Cities Development Initiative for Asia 2012). The only viable strategy for bridging Asia’s investment gap is thus to leverage private sector funding. Current Sources of Public Sector Financing for Green Investments this section describes the public sector mechanisms currently available for fnancing green investments, including their underlying public policy aspects, as well as associated incentives for both promoting investment and leveraging private sector funding. In practice, it means that you can have your single-story bungalow, empty industrial facility, or rice paddy in the middle of the central business district surrounded by 30-story buildings, but your land tax will be based on the value of the land as if you had a 30-story building on it. In 1980, Harrisburg, the capital of Pennsylvania, was identified as the second most financially distressed city in the United States. Municipal tax policy reforms were undertaken to shift taxes off of buildings and on to land. The resulting effect was that potentially developable sites were freed from speculation and under-use, while with buildings less burdened by taxes, developers with viable projects began restoring the city. This success prompted 17 other Pennsylvania municipalities to put this policy into place. All have evidenced benefits of economic regeneration as indicated by increased issuance of building permits and other criteria. In Hong Kong and Singapore, city authorities capture land value primarily through renting out government-owned land at rates reflecting the economic value of the activities thereon. The city-state of Singapore has a tax rate on land of 16%, this supplying funds equivalent to 40% of the government’s total budget. Meanwhile, Hong Kong, which was founded exclusively on land owned by the government, funds 40% of its budget from site rent. The city uses land rent—not subsidy—to fund its metro system and, in turn, building the metro increased the value of land. For Hong Kong’s metro system, land value capture (known as “betterment taxes”) represented a financial windfall. In the 1980s, the system was already showing a profit, partly due to the increase in land value along the metro line. However, it is interesting to observe how this income from land value increased and development was unexpected in the original viability projections. The non-fare revenue of the metro system comprises proceeds of land rent (direct betterment value), station commercial and related businesses such as retail and advertising sales (indirect betterment value), and other public mass transport investments. Land Value and Community Betterment Taxation in Britain: Proposals for Legislation and Practice. Practical political considerations complicate the implementation of this effective tax principle. There are sometimes shouts of “inequity” from granny, who inherited the said single-storey bungalow but has no income to support such a tax. One could retort that granny is a wealthy woman and can 308 Green Cities live very well from the proceeds of the sale, provided the capital gains and transfer taxes are not prohibitively high. As an aside, such transaction costs should be low in principle, as you the policy maker want a liquid land market in order to encourage densifcation and redevelopment that embraces green principles. If you are really soft-hearted, you can defer granny’s taxes until the land is sold, or, if you are soft-headed, you can exempt her completely during her occupancy.
Journal of Substance Abuse Costs of care for persons with opioid dependence Treatment asthma symptoms while pregnant , 35(1) asthma yeast , 87–92 asthma treatment vitamins . Cost and utilization outcomes of opioidbuprenorphine-naloxone treatment for prescription dependence treatments asthma definition bias . American Journal of Managed opioid dependence: A 2-phase randomized controlled Care asthmatic bronchitis coughing up blood , 17(Suppl. Long-term treatment with buprenorphine/ beneft of addiction interventions: A review of frst naloxone in primary care: Results at 2–5 years. Effect of buprenorphine implants on illicit Methadone maintenance therapy versus no opioid opioid use among abstinent adults with opioid replacement therapy for opioid dependence. Cochrane dependence treated with sublingual buprenorphine: Database of Systematic Reviews, 2009(3), 1–19. Journal of detoxifcation program: Retention, transfer to further Substance Abuse Treatment, 30, 159–163. Abstinence following detoxifcation buprenorphine taper vs maintenance therapy for and methadone maintenance treatment. American prescription opioid dependence: A randomized clinical Journal of Medicine, 65, 46–52. A randomized trial of six-month methadone pattern characteristics of successful tapers following maintenance with standard or minimal counseling methadone maintenance treatment: Results from versus 21-day methadone detoxifcation. Overdose after 85 Department of Health and Human Services, Offce detoxifcation: A prospective study. British Medical Journal, substance abuse treatment use among individuals with 326(7396), 959–960. A multi-center randomized trial of buprenorphinenaloxone versus clonidine for opioid detoxifcation: Findings from the National Institute on Drug Abuse Clinical Trials Network. Use Disorder Treatment Validated screening tools, symptom • For healthcare and addiction professionals, surveys, and other resources are readily policymakers, patients, and families available; this part lists many of them. Healthcare professionals in such settings address most personal healthcare needs, develop sustained partnerships with patients, and practice in the context of family and community. Healthcare opioid painkillers; professionals in these general settings are in an important position to identify, assess, and 589K, related to heroin. Screening can identify substance misuse in patients who wouldn’t otherwise discuss it Exhibit 2. Some patients may spontaneously reveal their substance use and Screening ask for help. This is more likely when they’re Screening can identify patients who may experiencing harmful consequences of substance have diseases or conditions related to their use. Remission: A medical term meaning a disappearance of signs and symptoms of the disease. Alcohol Screening Screening for alcohol misuse can identify Every medical practice should determine patients at increased risk for opioid use. Encourage patients in the one (oral and extended-release injectable nallatter category to maintain healthy behavior. Providers should reinforce healthy Among preventable causes of premature death, behaviors among patients who report “no use” smoking remains most prevalent, with more than and direct those who report “some use” for 480,000 deaths per year in the United States. The maximum score is 10; the higher the total score, the more severe Brief drug screens don’t indicate specifc the patient’s nicotine dependence. The two-item types of drugs used (nor does the longer Heaviness of Smoking Index (Exhibit 2. If providers use nonspecifc screens, they need to assess further which substances Drug Screening patients use and to what degree. Screening for illicit drug use and prescription medication misuse is clinically advantageous. How often during the last year have you had a have on a typical day when you are drinkingfi Single-Item Smoking Index Drug Screener Ask these two questions of current or recent How many times in the past year have smokers: you used an illegal drug or a prescription medication for nonmedical reasonsfi Two-Item Drug • 10 or less (no points) Use Disorder Screener for • 11–20 (1 point) Primary Care Clinics Serving • 21–30 (2 points) • 31 or more (3 points) U. Veterans Total score: Question 1: How many days in the past 12 1–2 points = very low dependence months have you used drugs other than 3 points = low to moderate dependence alcoholfi Set the Stage for Successful Assessment An in-person follow-up, regardless of referral the medical setting should create a welcoming • to specialty treatment. Brief Interventions and Brief Therapies for • A targeted physical exam for signs of opioid Substance Abuse, for more specifc examples withdrawal, intoxication, injection, and other 51 of interview questions and responses. By exploring that ambivalence history of the relationship between a patient’s and highlighting problem areas, providers can psychiatric symptoms and periods of substance help patients discover their own motivations use and abstinence. People Change52 discusses specifc applications of motivational interviewing in health care. As providers and staff build trust over To help determine the severity of patients’ future visits, they can get into more detailed substance use, explore historical features of their elements of the assessment. Asking about patients’ medical/ Histories should also explore current patterns surgical history can: of use,55 which inform treatment planning and include: • Reveal medical effects of substance use. Understanding patients’ motivations Providers should take specifc histories on the for change can be more useful than use of these substances. The same is true in treatment as patients engaging for details about the events and behaviors that voluntarily. Helping patients Similarly, identifying the features of successful explore why they want to change quit attempts can help guide treatment plan their drug use can motivate them and decisions. Such features may involve: prepare their providers to support them • Specifc treatment settings. Social factors that may infuence treatment engagement and retention, guide Conduct a Physical Examination treatment planning, and affect prognosis include: Perform a physical exam as soon as possible • Transportation and child care needs. Substance Physical fndings misuse substantially increases the risk of Drowsy but arousable intimate partner violence; screen all women Sleeping intermittently (“nodding off”) presenting for treatment for domestic Constricted pupils violence. The physical symptoms Early withdrawal Grade Lacrimation, were just the tip of the iceberg. There were times when I was Long-acting opioids: Restlessness Up to 36 hours after almost convinced that dying would Insomnia last use be better than what I was feeling. I Early withdrawal Grade Dilated pupils did not experience a moment of ease 2 Piloerection Short-acting opioids: for the frst 3 months, and it was 6 Muscle 8–24 hours after last months until I started to feel normal. Symptoms are similar to experiencing Fully developed Grade Tachycardia withdrawal 3 Hypertension gastroenteritis, severe infuenza, anxiety, and dysphoria concurrently. Short-acting opioids: Tachypnea 1–3 days after last use Fever Severity of withdrawal can indicate a patient’s Long-acting opioids: Anorexia or level of physical dependence and can inform nausea 72–96 hours after last use Extreme medication choices and dosing decisions. The restlessness duration of withdrawal depends on the specifc opioid from which the patient is withdrawing and Fully developed Grade Diarrhea, can last 1 to 4 weeks. After the initial withdrawal withdrawal 4 vomiting, or both phase is complete, many patients experience a Short-acting opioids: Dehydration prolonged phase of dysphoria, craving, insomnia, 1–3 days after last use Hyperglycemia and hyperalgesia that can last for weeks or months. Long-acting opioids: Hypotension 72–96 hours after last Curled-up Assess opioid withdrawal in the physical exam use position by noting physical signs and symptoms (Exhibit 2. Testing have few physical signs of use other than establishes a baseline of substances the patient signs of intoxication and withdrawal. Drug testing is an important tool in the arms, legs, hands, neck, or feet diagnosis and treatment of addiction. During ongoing pharmacotherapy fi Jaundice, caput medusa, palmar erythema, spider angiomata, or an with buprenorphine or methadone, enlarged or hardened liver secondary drug testing can confrm medication to liver disease. Patient–Provider Dialog: Talking About Drug Testing Frame drug testing in a clinical, nonpunitive way. For example, before obtaining a drug test, ask the patient, “What do you think we’ll fnd on this testfi Provider: When we assess patients for medication for opioid addiction, we always check urine samples for drugs. But I don’t trust the addiction because I know how powerful addiction can be, too. There are many drug testing panels; cutoffs for positive Testing for substances that can complicate results vary by laboratory. Benzodiazepine and other sedative only detect morphine, which is a metabolite misuse can increase the risk of overdose among of heroin, codeine, and some other opioids. When the typical screen will not detect methadone, assessing benzodiazepine use, note that typical buprenorphine, or fentanyl and may not detect benzodiazepine urine immunoassays will detect hydrocodone, hydromorphone, or oxycodone. Hydromorphone May not be 1–2 days May screen negative on opiate detected immunoassay. Marijuana TetrahydrocanInfrequent False positives possible with efavirenz, nabinol use of 1–3 days; ibuprofen, and pantoprazole. Providers should refer pregnant women • to prenatal care or, if qualifed, provide it Negative opioid test results require careful themselves. A patient may test negative for opioids despite presenting with opioid Liver function tests. In Treatment Planning or Referral addition, providers can suggest that family, Making Decisions About Treatment friends, and other potential recovery supports Start by sharing the diagnosis with patients. A great deal of time is spent in activities to obtain the opioid, use the opioid, or recover from its effects. Recurrent opioid use resulting in a failure to fulfll major role obligations at work, school, or home. Continued opioid use despite having persistent or recurrent social or interpersonal problems caused by or exacerbated by the effects of opioids. Important social, occupational, or recreational activities are given up or reduced because of opioid use. Continued opioid use despite knowledge of having a persistent or recurrent physical or psychological problem that’s likely to have been caused or exacerbated by the substance. A need for markedly increased amounts of opioids to achieve intoxication or desired effect b. A markedly diminished effect with continued use of the same amount of an opioid 11. The same—or a closely related—substance is taken to relieve or avoid withdrawal symptoms *This criterion is not met for individuals taking opioids solely under appropriate medical supervision. Part 3 covers the ancillary services, whether or not they choose details of their use. Services • Availability of and accessibility to treatment Support patient preferences for treatment. Patient program with or without pharmacotherapy characteristics can’t reliably predict greater likeli(Exhibit 2. Providers should Strategies to engage patients in shared ensure that patients understand the risks and decision making include: benefts of all options. Without this understand• Indicating to patients a desire to collaborate ing, patients can’t give truly informed consent. Treatment Setting Healthcare professionals cannot provide Based on Patient’s Choice of methadone in their clinics. If no treatment, which can last from a week to immediate openings are available, consider several weeks or more.
Others include maxillary-mandibular retrognathia or micro gnathia asthma symptoms only with a cold , positive family history of sleep apnea asthma nursing diagnosis , genetic syndromes that reduce upper airway patency asthmatic bronchitis with exacerbation . Compared with premenopausal females asthma quality of life , males are at in creased risk for obstructive sleep apnea hypopnea hfa asthma definition , possibly reflecting the influences of sex hormones on ventilatory control and body fat distribution, as well as because of gender differences in airway structure. Medications for mental disorders and medical conditions that tend to induce somnolence may worsen the course of apnea symptoms if these med ications are not managed carefully. Obstructive sleep apnea hypopnea has a strong genetic basis, as evidenced by the sig nificant familial aggregation of the apnea hypopnea index. The prevalence of obstructive sleep apnea hypopnea is approximately twice as high among the first-degree relatives of probands with obstructive sleep apnea hypopnea as compared with members of control families. One-third of the variance in the apnea hypopnea index is explained by shared fa milial factors. Although genetic markers with diagnostic or prognostic value are not yet available for use, eliciting a family history of obstructive sleep apnea hypopnea should in crease the clinical suspicion for the disorder. Culture-R elated Diagnostic Issues There is a potential for sleepiness and fatigue to be reported differently across cultures. In some groups, snoring may be considered a sign of health and thus may not trigger con cerns. Gender-Related Issues Females may more commonly report fatigue rather than sleepiness and may underreport snoring. Diagnostic Markers Polysomnography provides quantitative data on frequency of sleep-related respiratory disturbances and associated changes in oxygen saturation and sleep continuity. Polysom nographie findings in children differ from those in adults in that children demonstrate labored breathing, partial obstructive hypoventilation with cyclical desaturations, hypercapnia and paradoxical movements. Apnea hypopnea index levels as low as 2 are used to define thresholds of abnormality in children. Arterial blood gas measurements while the individual is awake are usually normal, but some individuals can have waking hypoxemia or hypercapnia. This pattern should alert the clinician to the possibility of coexisting lung disease or hypoventilation. Individuals with severe nocturnal oxygen desaturation may also have el evated hemoglobin or hematocrit values. Functional Consequences of Obstructive Sleep Apnea Hypopnea More than 50% of individuals with moderate to severe obstructive sleep apnea hypopnea report symptoms of daytime sleepiness. A twofold increased risk of occupational accidents has been reported in association with symptoms of snoring and sleepiness. Motor vehicle crashes also have been reported to be as much as sevenfold higher among individuals with elevated apnea hypopnea index values. Clinicians should be cognizant of state govern ment requirements for reporting this disorder, especially in relationship to commercial drivers. Reduced scores on measures of health-related quality of life are common in individ uals with obstructive sleep apnea hypopnea, with the largest decrements observed in the physical and vitality subscales. Individuals with obstructive sleep apnea hypopnea must be differentiated from individuals with primary snoring. Individuals with obstructive sleep apnea hypopnea may additionally report nocturnal gasping and choking. The presence of sleepiness or other daytime symptoms not explained by other etiologies suggests the diagnosis of obstructive sleep apnea hypop nea, but this differentiation requires polysomnography. Definitive differential diagnosis between hypersomnia, central sleep apnea, sleep-related hypoventilation, and obstructive sleep apnea hypopnea also requires polysomnographic studies. Obstructive sleep apnea hypopnea must be differentiated from other causes of sleepi ness, such as narcolepsy, hypersonmia, and circadian rhythm sleep disorders. Obstructive sleep apnea hypopnea can be differentiated from narcolepsy by the absence of cataplexy, sleep-related hallucinations, and sleep paralysis and by the presence of loud snoring, gasping during sleep, or observed apneas in sleep. Daytime sleep episodes in narcolepsy are characteristically shorter, more refreshing, and more often associated with dreaming. Obstructive sleep apnea hypopnea shows characteristic apneas and hypopneas and oxy gen desaturation during nocturnal polysomnographic studies. Narcolepsy, like obstructive sleep apnea hypopnea, may be associated with obesity, and some individuals have concurrent narcolepsy and obstructive sleep apnea hypopnea. A diagnosis of narco lepsy does not exclude the diagnosis of obstructive sleep apnea hypopnea, as the two con ditions may co-occur. For individuals complaining of difficulty initiating or maintaining sleep or early-moming awakenings, insomnia disorder can be differentiated from obstruc tive sleep apnea hypopnea by the absence of snoring and the absence of the history, signs, and symptoms characteristic of the latter disorder. However, insomnia and obstructive sleep apnea hypopnea may coexist, and if so, both disorders may need to be addressed concurrently to improve sleep. Nocturnal panic attacks may include symptoms of gasping or choking during sleep that may be difficult to distinguish clinically from obstructive sleep apnea hy popnea. However, the lower frequency of episodes, intense autonomic arousal, and lack of excessive sleepiness differentiate nocturnal panic attacks from obstructive sleep apnea hy popnea. Polysomnography in individuals with nocturnal panic attacks does not reveal the typical pattern of apneas or oxygen desaturation characteristic of obstructive sleep apnea hypopnea. Individuals with obstructive sleep apnea hypopnea do not provide a history of daytime panic attacks. Attention-defidt/hyperactivity disorder in chil dren may include symptoms of inattention, academic impairment, hyperactivity, and in ternalizing behaviors, all of which may also be symptoms of childhood obstructive sleep apnea hypopnea. The presence of other symptoms and signs of childhood obstructive sleep apnea hypopnea. Obstruc tive sleep apnea hypopnea and attention-deficit/hyperactivity disorder may commonly co-occur, and there may be causal links between them; therefore, risk factors such as en larged tonsils, obesity, or a family history of sleep apnea may help alert the clinician to their co-occurrence. Substance use and substance withdrawal (including medications) can produce insomnia or hypersomnia. A careful his tory is usually sufficient to identify the relevant substance/medication, and follow-up shows improvement of the sleep disturbance after discontinuation of the substance/med ication. An individual with symptoms and signs consistent with obstructive sleep apnea hypopnea should receive that diagnosis, even in the presence of concurrent substance use that is exacerbating the condition. Risk esti mates vary from 30% to as much as 300% for moderate to severe obstructive sleep apnea hypopnea. Obstructive sleep apnea hypopnea also may occur with in creased frequency in association with a number of medical or neurological conditions. As many as one-third of individuals referred for evaluation of obstructive sleep apnea hypopnea report symptoms of depression, with as many of 10% having depression scores consistent with moderate to severe depression. Severity of obstructive sleep apnea hypop nea, as measured by the apnea hypopnea index, has been foimd to be correlated wi^ se verity of symptoms of depression. Specify current severity: Severity of central sleep apnea is graded according to the frequency of the breathing disturbances as well as the extent of associated oxygen desaturation and sleep frag mentation that occur as a consequence of repetitive respiratory disturbances. Subtypes Idiopathic central sleep apnea and Cheyne-Stokes breathing are characterized by increased gain of the ventilatory control system, also referred to as high loop gain, which leads to in stability in ventilation and PaC02 levels. This instability is termed periodic breathing and can be recognized by hyperventilation alternating with hypoventilation. Individuals with these disorders typically have pC02 levels while awake that are slightly hypocapneic or normocapneic. Central sleep apnea may also manifest during initiation of treatment of ob structive sleep apnea hypopnea or may occur in association with obstructive sleep apnea hypopnea syndrome (termed complex sleep apnea). The occurrence of central sleep apnea in association with obstructive sleep apnea is also considered to be due to high loop gain. In contrast, the pathogenesis of central sleep apnea comorbid with opioid use has been at tributed to the effects of opioids on the respiratory rhythm generators in the medulla as well as to its differential effects on hypoxic versus hypercapneic respiratory drive. Individuals receiving chronic methadone maintenance therapy have been noted to have increased sonmolence and de pression, although the role of breathing disorders associated with opioid medication in caus ing these problems has not been studied. In individuals with severe CheyneStokes breathing, the pattern can also be observed during resting wakefulness, a finding that is thought to be a poor prognostic marker for mortality. Diagnostic Features Central sleep apnea disorders are characterized by repeated episodes of apneas and hypopneas during sleep caused by variability in respiratory effort. These are disorders of ventilatory control in which respiratory events occur in a periodic or intermittent pattern. Idiopathic central sleep apnea is characterized by sleepiness, insomnia, and awakenings due to dyspnea in association with five or more central apneas per hour of sleep. Central sleep apnea occurring in individuals with heart failure, stroke, or renal failure typically have a breathing pattern called Cheyne-Stokes breathing, which is characterized by a pattern of periodic crescendo-decrescendo variation in tidal volume that results in central apneas and hypopneas occurring at a frequency of at least five events per hour that are accompa nied by frequent arousals. Central and obstructive sleep apneas may coexist; the ratio of central to obstructive apneas/hypopneas may be used to identify which condition is pre dominant. Alterations in neuromuscular control of breathing can occur in association with med ications or substances used in individuals with mental health conditions, which can cause or exacerbate impairments of respiratory rhythm and ventilation. Individuals taking these medications have a sleep-related breathing disorder that could contribute to sleep distur bances and symptoms such as sleepiness, confusion, and depression. Specifically, chronic use of long-acting opioid medications is often associated with impairment of respiratory con trol leading to central sleep apnea. Associated Features Supporting Diagnosis Individuals with central sleep apnea hypopneas can manifest with sleepiness or insomnia. Obstructive sleep apnea hypopnea can coexist with Cheyne-Stokes breathing, and thus snoring and abruptly terminating apneas may be ob served during sleep. Prevaience the prevalence of idiopathic central sleep apnea is unknown but thought to be rare. The prevalence of Cheyne-Stokes breathing is high in individuals with depressed cardiac ven tricular ejection fraction. In individuals with an ejection fraction of less than 45%, the prev alence has been reported to be 20% or higher. The male-to-female ratio for prevalence is even more highly skewed toward males than for obstructive sleep apnea hypopnea. Cheyne-Stokes breath ing occurs in approximately 20% of individuals with acute stroke. Central sleep apnea comorbid with opioid use occurs in approximately 30% of individuals taking chronic opi oids for nonmalignant pain and similarly in individuals receiving methadone mainte nance therapy. Development and Course the onset of Cheyne-Stokes breathing appears tied to the development of heart failure. The Cheyne-Stokes breathing pattern is associated with oscillations in heart rate, blood pres sure and oxygen desaturation, and elevated sympathetic nervous system activity that can promote progression of heart failure. The clinical significance of Cheyne-Stokes breathing in the setting of stroke is not known, but Cheyne-Stokes breathing may be a transient find ing that resolves with time after acute stroke. Central sleep apnea comorbid with opioid use has been documented with chronic use. Cheyne-Stokes breathing is frequently present in individu als with heart failure. The coexistence of atrial fibrillation further increases risk, as do older age and male gender.
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