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Aims In atrial fibrillation (AF) patients, untreated sleep-disordered breathing (SDB) is associated with lower success rates of rhythm control strategies and as such structured SDB testing is recommended. Herein, we describe the implementation of a virtual SDB management pathway in an AF outpatient clinic and examine the utility and feasibility of this new approach. Methods and results Prospectively, consecutive AF patients accepted for AF catheter ablation procedures without previous diagnosis of SDB were digitally referred to a virtual SDB management pathway and instructed to use WatchPAT-ONE (ITAMAR) for one night. Results were automatically transferred to a virtual sleep laboratory, upon which a teleconsultation with a sleep physician was planned. Patient experience was measured using surveys. SDB testing was performed in 119 consecutive patients scheduled for AF catheter ablation procedures. The median time from digital referral to finalization of the sleep study report was 18 [11–24] days. In total, 65 patients (55%) were diagnosed with moderate-to-severe SDB. Patients with SDB were prescribed more cardiovascular drugs and had higher body mass indices (BMI, 29 ± 3.3 vs. 27 ± 4.4kg/m2, P Conclusion This novel virtual AF management pathway allowed remote SDB testing in AF outpatient clinics with a short time to diagnosis and high patient satisfaction. Structured SDB testing results in a high detection of previously unknown SDB in AF patients scheduled for AF ablation.

Aims Sleep apnoea and congestive heart failure (CHF) commonly co‐exist, but their interaction is unclear. Metabolomics may clarify their interaction and relationships to outcome. Methods and results We assayed 372 circulating metabolites and lipids in 1919 and 1524 participants of the Framingham Heart Study (FHS) (mean age 54 ± 10 years, 53% women) and Women's Health Initiative (WHI) (mean age 67 ± 7 years), respectively. We used linear and Cox regression to relate plasma concentrations of metabolites and lipids to echocardiographic parameters; CHF and its subtypes heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF); and sleep indices. Adenine dinucleotide phosphate (ADP) associated with left ventricular (LV) fractional shortening; phosphocreatine with LV wall thickness; lysosomal storage molecule sphingomyelin 18:2 with LV mass; and nicotine metabolite cotinine with time spent with an oxygen saturation less than 90% (β = 2.3 min, P = 2.3 × 10−5). Pro‐hypertrophic metabolite hydroxyglutarate partly mediated the association between LV wall thickness and HFpEF. Central sleep apnoea was significantly associated with HFpEF (P = 0.03) but not HFrEF (P = 0.5). There were three significant metabolite canonical variates, one of which conferred protection from cardiovascular death [hazard ratio = 0.3 (0.11, 0.81), P = 0.02]. Conclusions Energetic metabolites were associated with cardiac function; energy‐ and lipid‐storage metabolites with LV wall thickness and mass; plasma levels of nicotine metabolite cotinine were associated with increased time spent with a sleep oxygen saturation less than 90%, a clinically significant marker of outcome, indicating a significant hazard for smokers who have sleep apnoea.

BackgroundThe optimal interface for the delivery of home non-invasive ventilation (NIV) to treat chronic respiratory failure has not yet been determined. The aim of this individual participant data (IPD) meta-analysis was to compare the effect of nasal and oronasal masks on treatment efficacy and adherence in patients with COPD and obesity hypoventilation syndrome (OHS).MethodsWe searched Medline and Cochrane Central Register of Controlled Trials for prospective randomised controlled trials (RCTs) of at least 1 month’s duration, published between January 1994 and April 2019, that assessed NIV efficacy in patients with OHS and COPD. The main outcomes were diurnal PaCO2, PaO2 and NIV adherence (PROSPERO CRD42019132398).FindingsOf 1576 articles identified, 34 RCTs met the inclusion criteria and IPD were obtained for 18. Ten RCTs were excluded because only one type of mask was used, or mask data were missing. Data from 8 RCTs, including 290 IPD, underwent meta-analysis. Oronasal masks were used in 86% of cases. There were no differences between oronasal and nasal masks for PaCO2 (0.61 mm Hg (95% CI −2.15 to 3.38); p=0.68), PaO2 (−0.00 mm Hg (95% CI −4.59 to 4.58); p=1) or NIV adherence (0·29 hour/day (95% CI −0.74 to 1.32); p=0.58). There was no interaction between the underlying pathology and the effect of mask type on any outcome.InterpretationOronasal masks are the most used interface for the delivery of home NIV in patients with OHS and COPD; however, there is no difference in the efficacy or tolerance of oronasal or nasal masks.

Obstructive sleep apnoea (OSA) constitutes a public health problem, with various systemic consequences that can increase cardiovascular morbidity and mortality as well as increase healthcare expenditure. This review discusses the rationale and effects of using general physical exercise, oropharyngeal exercises, and respiratory muscle training as an adjunctive treatment for patients with sleep apnoea. The recommended treatment for OSA is the use of continuous positive airway pressure, which is a therapy that prevents apnoea events by keeping the airways open. In the last decade, coadjuvant treatments that aim to support weight loss (including diet and physical exercise) and oropharyngeal exercises have been proposed to lower the apnoea/hypopnoea index among patients with OSA. Based on the available evidence, health professionals could decide to incorporate these therapeutic strategies to manage patients with sleep apnoea.

Objectives: (1) To assess the risk of Obstructive Sleep Apnea (OSA) using a pre-designed questionnaire; (2) To assess the periodontal parameters like pocket probing depth (PPD) and clinical attachment loss (CAL) in the study subjects and (3) To determine the association between the shared risk factors of OSA and periodontitis. Background of the Study: Periodontitis is a microbially associated, host-mediated inflammatory disease that results in the loss of periodontal attachment. It has multifactorial etiology and has been linked to an array of systemic diseases. Though both periodontitis and obstructive sleep apnoea (OSA) share some common risk factors, the insight into the hypothetical speculative link remains vague. This study intended to probe into the association between periodontitis and OSA. Methodology: A cross-sectional study was conducted on 250 subjects. The subjects were explained the nature of the study and written informed consent was obtained for participation in the study. The patients were administered a STOP-BANG questionnaire following which the periodontal parameters were recorded. The data obtained was analyzed by descriptive and inferential statistics. Results: A statistically significant increase in PPD and CAL scores were seen with the increase in OSA scores. A significant moderate positive correlation was found between OSA scores and PPD [r = 0.58, P < 0.001] and CAL [r = 0.55, P = 0.001]. Males were at increased risk for OSA and periodontitis. Age, hypertension and BMI which are the risk factors for periodontitis were also significantly higher in subjects at high risk for OSA. Conclusion: This study found a moderate positive association between periodontitis and OSA.

Surgery for adult obstructive sleep apnoea (OSA) plays a key role in contemporary management paradigms, most frequently as either a second‐line treatment or in a facilitatory capacity. This committee, comprising two sleep surgeons and three sleep physicians, was established to give clarity to that role and expand upon its appropriate use in Australasia. This position statement has been reviewed and approved by the Australasian Sleep Association (ASA) Clinical Committee.

The SERVE-HF study revealed no benefit of adaptive servoventilation (ASV) versus guideline-based medical treatment in patients with symptomatic heart failure, an ejection fraction (EF) ≤45% and a predominance of central events (apnoea-hypopnea Index [AHI] 15/h). Because both all-cause and cardiovascular mortality were higher in the ASV group, an EF ≤ 45% in combination with AHI 15/h, central apnoea-hyponoea index [CAHI/AHI] 50% and central apnoea index [CAI] 10/h were subsequently listed as contraindications for ASV. The intention of our study was to analyse the clinical relevance of this limitation.Data were analysed retrospectively for patients treated with ASV who received follow-up echocardiography to identify contraindications for ASV.Echocardiography was conducted in 23 patients. The echocardiogram was normal in 10 cases, a left ventricular hypertrophy with normal EF was found in 8 patients, there was an EF 45-50% in 2 cases and a valvular aortic stenosis (grade II) with normal EF was found in 1 case. EF45% was present in just 2 cases, and only 1 of these patients also had more than 50% central events in the diagnostic night.The population typically treated with ASV is entirely different from the study population in SERVE-HF, as nearly half of the patients treated with ASV showed a normal echocardiogram. Thus, the modified indication for ASV has little impact on the majority of treated patients. The current pathomechanistic hypothesis of central apnoea must be reviewed.Die SERVE-HF-Studie ergab keinen Vorteil der adaptiven Servoventilation (ASV) gegenüber der leitlinienbasierten medizinischen Therapie von Patienten mit symptomatischer Herzinsuffizienz, einer Ejektionsfraktion (EF) ≤45% und überwiegend zentralen Ereignissen (Apnoe-Hypopnoe-Index [AHI]15/h). Weil die Gesamt- und die kardiovaskulär bedingte Mortalität in der ASV-Gruppe höher waren, wurden eine EF ≤45% in Kombination mit einem AHI 15/h, einem zentralen Apnoe-Hypopnoe-Index (CAHI)/AHI50% und einem zentralen Apnoe-Index (CAI)10/h als Kontraindikationen für die ASV aufgeführt. Ziel der vorliegenden Studie war es, die klinische Relevanz dieser Einschränkungen zu untersuchen.Retrospektiv wurden die Daten von mit ASV behandelten Patienten ausgewertet, bei denen in der Nachsorge eine Echokardiographie zur Feststellung von Kontraindikationen für eine ASV erfolgt war.Bei 23 Patienten wurde eine Echokardiographie durchgeführt. In 10 Fällen war der Befund der Echokardiographie normal, eine linksventrikuläre Hypertrophie mit normaler EF wurde bei 8 Patienten festgestellt, eine EF von 45–50% bestand in 2 Fällen und eine valvuläre Aortenstenose (Grad II) mit normaler EF in einem Fall. Eine EF45% bestand in nur 2 Fällen, und lediglich einer dieser Patienten wies mehr als 50% zentrale Ereignisse in der diagnostisch ausgewerteten Nacht auf.Die gewöhnlich mit ASV behandelte Population stellt sich völlig anders dar als die Studienpopulation in der SERVE-HF-Studie, da fast die Hälfte der Patienten mit ASV-Therapie einen normalen Echokardiographiebefund aufwies. Daher hat die modifizierte Indikation für eine ASV nur geringen Einfluss auf die Mehrzahl der behandelten Patienten. Die aktuelle Hypothese zu den Pathomechanismen der zentralen Apnoe muss überprüft werden.

ObjectivesUp to 77% of patients with obstructive sleep apnoea (OSA) have positional OSA (POSA) but traditional positional therapy (PT) methods have failed as they were poorly tolerated. New convenient vibratory PT devices have been invented but while recent studies suggest high treatment efficacy and adherence, there are no published data comparing these devices directly with continuous positive airway pressure (CPAP). Our objective is to evaluate if a convenient vibratory PT device is non-inferior to CPAP in POSA treatment.MethodsIn this crossover randomised controlled trial, we enrolled patients with POSA with significant daytime sleepiness (Epworth Sleepiness Scale (ESS)≥10). POSA diagnosis was based on: (1) total Apnoea/Hypopnoea Index (AHI)>10/hour and non-supine AHINCT03125512).Results40 patients completed the trial between April 2017 and December 2018. Difference in ESS after 8 weeks of device use (PT minus CPAP) was 2.0 (95% CI 0.68 to 3.32), exceeding our predetermined non-inferiority margin of 1.5. AHI on CPAP was lower than with PT (4.0±3.2 vs 13.0±13.8 events/hour, respectively, p=0.001), although both were lower than at baseline. Time spent supine was significantly lower with PT than CPAP (pConclusionsThe non-inferiority ESS endpoint for PT compared with CPAP was not met and the results were inconclusive. Future trials with larger sample sizes or in less symptomatic patients are warranted to provide further insight into the role of these new vibratory PT devices.

Introduction The severity of obstructive sleep apnoea (OSA) is highly variable on a night-to-night basis. Patients are commonly categorised based on the severity of their OSA, and this is then used to influence management and reimbursement, including continuous positive airway pressure (CPAP). We aimed to establish to what extent the OSA severity category changes during two periods of OSA, based on mean and maximum oxygen desaturation index (ODI). Methods Patients with a diagnosis of moderate to severe OSA who had been on CPAP for greater than 1 year were included in this study. Subjects underwent two periods of CPAP withdrawal for four nights each. Results Twenty-five patients completed the study. Based on the mean ODI of the four nights, 14 (56%) patients changed OSA severity categorisation, with three (12%) changing category to mild. Based on the maximum ODI of the four nights, nine (36%) patients changed OSA severity categorisation, with one (4%) changing category to mild. One third to a half of patients’ OSA severity category changed between the two periods of four night’s CPAP withdrawal. Conclusions OSA is highly variable on a period-to-period basis as well as on a night-to-night basis. We believe the concept of patients having a definable and ‘real’ level of OSA severity is therefore flawed. OSA severity should be based mainly on symptoms, as these are the dominant reasons for treatment, and the sleep study should be used qualitatively to ascertain whether respiratory events are the likely cause of the symptoms. Trial Registration ISRCTN17987510.

Continuous positive airway pressure (CPAP) being a gold standard treatment to open the upper airway by application of controlled compressed air is still not a widely accepted mode of treatment among obstructive sleep apnea (OSA) individuals. To improve patency of upper airway space and reduce the risk of sleep apnoea, it is essential to provide mandibular advancement devices (MADs) that could provide non-continuous positive airway pressure (non-CPAP) for patients with OSA. Availability of prefabricated oral appliances (OAs) like MADs, tongue holding devices reduced the chair-side fabrication time but has poor adaptation, excessive salivation, and deprivation of sleep. Customized OAs can overcome these challenges, but their fabrication for an edentulous individual is challenging due to the absence of teeth and the encroachment of tongue space by the device. This clinical report gives an insight into the clinical and technical aspect of fabrication of MAD with tongue retaining space for an edentulous individual with OSA.

We acknowledge the work of Professor O’Connor-Reina who designed and produced the Airway Gym® app for his patients and whose work was central to this research., Study objectives: To evaluate tone, apraxia and stereognosis dysfunctions in patients with SDB compared with healthy controls, and to monitor the effectiveness of Airway Gym® as an easy-to- use myofunctional therapy (MT) modality in terms of the tongue's motor and sensory responses, comparing results before and after therapy. Methods: This was a prospective, non-randomised pilot study of 25 patients with moderate to severe obstructive sleep apnoea-hypopnoea syndrome (OSAHS), 25 patients with primary snoring (PS) and 20 healthy controls. Qualitative and quantitative instruments—Iowa Oral Performance Instrument (IOPI), lingual apraxia and stereognosis tests were used to assess tongue sensorimotor function. Results: 22 patients with PS, 21 with OSAHS and all 20 controls ended the therapy. In OSAHS, the Epworth Sleepiness Scale score decreased from 16 ± 7.3 to 12 ± 4.5 after therapy (p = 0.53). In PS and OSAHS groups, the IOPI scores increased significantly. These measures did not change significantly in the controls. Lingual apraxia testing showed that controls performed all the manoeuvres, whereas PS 5.6 ± 1.4 and OSAHS 4.5 ± 1.9 (p = 0.14). In the stereognosis test, the mean number of figures recognised was 2.6 ± 2.2 in OSAHS, 3.3±1.2 in PS and 5.7±0.9 in control group (p < 0.05). Patients with OSAHS recognised circles and ovals less often. Conclusion: Using the Airway Gym®app produced improvements in sensorimotor tongue function in patients with SDB, due to continuous stimulation of the brain based on proprioceptive training required to localise responses when doing the exercises.

Rationale Adaptive servo ventilation (ASV) is contraindicated in patients with systolic heart failure (HF) who have a left ventricular ejection fraction (LVEF) below 45% and predominant central sleep apnoea (CSA). However, the effects of ASV in other HF subgroups have not been clearly defined. Objective The European, multicentre, prospective, observational cohort trial, FACE, evaluated the effects of ASV therapy on morbidity and mortality in patients with HF with sleep-disordered breathing (SDB); 3-month outcomes in patient subgroups defined using latent class analysis (LCA) are presented. Methods Consecutive patients with HF with predominant CSA (±obstructive sleep apnoea) indicated for ASV were included from 2009 to 2018; the non-ASV group included patients who refused/were noncompliant with ASV. The primary endpoint was time to composite first event (all-cause death, lifesaving cardiovascular intervention or unplanned hospitalisation for worsening of chronic HF). Measurements and main results Baseline assessments were performed in 503 patients, and 482 underwent 3-month follow-up. LCA identified six discrete patient clusters characterised by variations in LVEF, SDB type, age, comorbidities and ASV acceptance. The 3- month rate of primary outcome events was significantly higher in cluster 1 patients (predominantly men, low LVEF, severe HF, CSA; 13.9% vs 1.5%–5% in other clusters, p

Sleep-disordered breathing (SDB) is extremely common in heart failure (HF) and it carries with it adverse symptoms and impaired survival. Sleep-disordered breathing has two main types; obstructive sleep apnoea (OSA) and central sleep apnoea (CSA), which can overlap. The differentiation between CSA and OSA is important and is recommended in recent HF guidelines, by recommending a formal sleep study. The reason is that for OSA the main therapy is a positive pressure airway mask, whereas for patients with HFrEF and CSA this mask therapy actually increases cardiovascular mortality, and therefore alternative therapies are required, such as implantable phrenic nerve stimulation to improve sleep and related daytime symptoms attributable to the CSA. This article discusses the detection, screening, and monitoring of SDB in HF patients.

Road accidents are among the main fatalities worldwide and drowsy driving is a significant cause of road deaths where drivers are at fault. There are well known diseases which impair sensory and cognitive functions and can cause sleepiness during driving. Such diseases can be an important contraindication to driving because they may have an adverse effect on its safety. Thus, medical examinations for drivers should also be directed at identifying any possible conditions posing risks for driving safety. Occupational medicine specialists should look for symptoms of locomotor and sleep-related breathing disorders as these are medical conditions which could preclude a person from driving. In this case report, the authors describe a professional driver with chest deformity and present a pioneering attempt at assessing his medical fitness to drive. It is also explained why scoliosis can impair driving ability and how it should be diagnosed and treated. Finally, the authors describe how they used driving simulator tests as part of their diagnosis and suggest a relevant treatment regimen. Int J Occup Med Environ Health. 2019;32(5):735-45.

Objectives: Tooth wear is a common finding in adult patients with dental sleep disorders. The aim of this paper was to review the literature on the possible associations between tooth wear and the following dental sleep disorders: sleep‐related oro‐facial pain, oral moistening disorders, gastroesophageal reflux disease (GERD), obstructive sleep apnoea syndrome (OSAS) and sleep bruxism.Methods: A PubMed search was performed on 1 June 2018 using MeSH terms in the following query: Tooth Wear AND (Facial Pain OR Temporomandibular Joint Disorders OR Xerostomia OR Sialorrhea OR Gastroesophageal Reflux OR Sleep Apnea Syndrome OR Sleep Bruxism).Results: The query yielded 706 reports on tooth wear and the mentioned dental sleep disorders. Several associations between tooth wear and the dental sleep disorders were suggested in the literature. It could be concluded that: (a) tooth wear is associated with dental pain and/or hypersensitivity; (b) oral dryness is associated with tooth wear, oro‐facial pain and sleep bruxism; (c) GERD is associated with tooth wear, oro‐facial pain, oral dryness, OSAS and sleep bruxism; (d) OSAS is associated with oral dryness, GERD and sleep bruxism; and (e) sleep bruxism is associated with tooth wear.Conclusions: Tooth wear is associated with the dental sleep disorders oro‐facial pain, oral dryness, GERD and sleep bruxism. The dental sleep disorders are interlinked with each other, which leads to indirect associations as well, and makes the consequences of each single condition difficult to disentangle. Knowledge of these associations is clinically relevant, but more research is needed to confirm their validity.

Purpose Nasal continuous positive airway pressure (CPAP) alleviates sleepiness in patients with obstructive sleep apnoea syndrome (OSAS), but part of OSAS patients keep gaining weight. Leptin and insulin-like growth factor-1 (IGF-1) interact with energy balance, and CPAP therapy has been suggested to influence these endocrine factors. We hypothesised that leptin would decrease during long-term CPAP therapy, and weight gain would associate with OSAS severity, lower CPAP adherence, lower IGF-1, and leptin concentrations. Methods Consecutive patients (n = 223) referred to sleep study with suspected OSAS were enrolled. Patients underwent cardiorespiratory polygraphy at baseline. Questionnaires were completed, and blood samples were drawn both at baseline and after 3 years. A total of 149 (67%; M 65, F 84) patients completed the follow-up. Plasma samples were available from 114 patients, 109 of which with CPAP adherence data (49 CPAP users, 60 non-users). Results At baseline, the CPAP users were more obese and had more severe OSAS than the non-users. Leptin concentrations did not differ. After follow-up, leptin concentrations were higher in CPAP users (30.2 ng/ml vs. 16.8 ng/ml; p = 0.001). In regression analysis, increase in leptin concentrations was independent of age, baseline body mass index (BMI), or the change in BMI. Leptin concentrations increased among females (− 8.9 vs. 12.7 ng/ml; p

Background: Excessive daytime sleepiness (EDS) is a contributing factor to road traffic accidents. It is commonly assessed using self-administered questionnaires. These assessments are important information when discussing with the Driver and Vehicle Licensing Agency (DVLA) about fitness-to-drive. We hypothesised that patients may be confounded in their assessments after being informed about these potential implications. Patients and methods: This was a prospective single-centre study. Patients attending clinics for sleep-disordered breathing were asked to fill in the Epworth Sleepiness Scale (ESS) and the Stanford Sleepiness Scale (SSS). Following their consultation, patients were informed about EDS in the context of driving and that the DVLA might request information based on their self-assessed sleepiness. They were then asked to complete the same questionnaires again. Parameters recorded included age, gender, body mass index (BMI), driving licence holder, and collar size. An ESS score above 10 points was defined as EDS. Results: One hundred twenty-two subjects were studied (age 59.4 years (15.2); 72 males; BMI 32.1 kg/m2 (8.3), driving licence held for 25.2 years (20.6) (n = 94); collar size 42.7 cm (5.0)). There was no difference in the ESS [8 (8) vs 8 (8) points; p = 0.289] or the SSS [2 (2) vs 2 (2) points; p = 0.320] between the two occasions, although seven patients (5.7%) changed their scores from “sleepy” to “non-sleepy” and four patients (3.3%) from “non-sleepy” to “sleepy”. Conclusion: Providing patients with information about the risk of driving in the context of sleepiness does not significantly change how they score their symptoms using self-administered questionnaires; only about 9.0% of the patients had inconsistent results.

Background and Aims: Obstructive sleep apnoea (OSA) has an estimated prevalence of 2%–4% in adult population and is increasing. Most of these are detected late which is the cause for higher perioperative morbidity. This survey was aimed to seek the level of knowledge and attitude of Indian anaesthesiologists towards OSA. Methods: The OSA Knowledge and Attitude (OSAKA) questionnaire (23-statements) was distributed to the anaesthesiologists attending the difficult airway conference in December 2017. The first section has 18 statements pertaining to OSA knowledge. The second section consists of five statements to evaluate self-confidence in the management of OSA. Age, gender, professional title, type of hospital, years of experience, and bariatric experience were analysed. Results: 205 out of 350 participants responded. In all, 201 (57.4%) fully completed responses were analysed. The mean ± standard deviation knowledge and attitude scores were 12.01 ± 2.88 (66.72% ± 16%) and 18.16 ± 3.75 (72.64% ± 15%) respectively. On exclusion of junior residents (n = 56), knowledge and attitude scores of qualified anaesthesiologists were 12.7 ± 2.55 (70.55% ± 14.16%) and 18.78 ± 3.91 (75.12% ± 15.64%), respectively. Anaesthesiologists with bariatric experience had a significantly higher attitude score when compared with those who do not practice bariatric surgeries (P < 0.01). There is weak but significant, positive linear correlation between knowledge and attitude score (rs= 0.370, P < 0.01). Conclusion: Deficit of adequate knowledge about OSA exists among Indian anaesthesiologists. Experience of managing cases with OSA seems to improve knowledge and attitude towards OSA.

Myofunctional therapy (MFT) may have a role in improving muscle tone and alleviating upper airway collapse in sleep-disordered breathing. The purposes of this state-of-the-art review are to first review systematically the current literature on the effectiveness of MFT in treating sleep-disordered breathing and then to provide an overview of the current understanding of patient selection, side effects, type and duration of exercises, guidance of exercise performance, evaluation of results, and how best to promote adherence. PubMed (Medline), the Cochrane Library, and the EMBASE, Scopus and SciELO databases were checked for relevant studies by three authors, and a total of 23 studies were included. This review focuses only on adults with sleep-disordered breathing. The available evidence shows a positive effect of MFT in reducing sleep apnoea, as measured using polysomnography and clinical variables (including snoring). There is no evidence of the utility of MFT for treating upper airway resistance syndrome, the duration of the effects of MFT, or regarding which MFT protocol is best. Despite these knowledge gaps, the available evidence suggests that MFT is a safe treatment modality.

ObjectivesOver 1 billion individuals worldwide experience some form of sleep apnoea, and this number is steadily rising. Obstructive sleep apnoea (OSA) can negatively influence one’s quality of life and potentially increase mortality risk. However, the association between OSA and mortality has not been reliably estimated. This meta-analysis estimates the risk of all-cause and cardiovascular mortality in individuals with OSA.DesignSystematic review and meta-analysis.Data sourcesMEDLINE, Cochrane Library, Scopus and Joanna Briggs Institute Evidence-Based Practice databases were searched from inception through 1 January 2020.Eligibility criteria for selecting studiesWe included observational studies assessing the association of sudden deaths in individuals with and without OSA.Data extraction and synthesisTwo independent reviewers (AES and ESH) extracted data and assessed the risk of bias using the Newcastle-Ottawa Scale quality assessment tool. Data were pooled using the random-effects models and reported as risk ratios (RRs) with 95% CIs. Heterogeneity was quantified with I2 statistic.ResultsWe identified 22 observational studies (n=42 099 participants). The mean age was 62 years and 64% were men. OSA was associated with all-cause sudden death (RR=1.74, 95% CI: 1.44 to 2.10, I2=72%) and cardiovascular mortality (RR=1.94, 95% CI: 1.39 to 2.70, I2=32%). A marginally significant dose–response relationship between severity of OSA and the risk of death was observed (p for interaction=0.05): mild OSA (RR=1.16, 95% CI: 0.70 to 1.93), moderate OSA (RR=1.72, 95% CI: 1.11 to 2.67) and severe OSA (RR=2.87, 95% CI: 1.70 to 4.85). Meta-regression analysis showed that older age was a significant contributing factor in the relationship between OSA and mortality. The median study methodological quality was considered high.ConclusionsOSA is a significant risk factor for all-cause mortality and cardiac mortality. Prevention and treatment strategies to optimise survival and quality of life in individuals with OSA are urgently needed.PROSPERO registration numberCRD42020164941.

Intermittent hypoxia in obstructive sleep apnoea (OSA) is related to inflammation and metabolic abnormalities. Soluble low-density lipoprotein receptor-related protein-1 (sLRP-1) is involved in anti-inflammatory and metabolic processes. However, its ligand, calreticulin (CALR) promotes pro-inflammatory responses and apoptosis. Our aim was to analyse the levels of these biomarkers in OSA. We recruited 46 patients with OSA and 30 control subjects. Inpatient sleep study was performed and fasting plasma samples were collected. Triglyceride glucose index (TyG) and atherogenic index of plasma (AIP) were calculated. Plasma sLRP-1 levels were significantly lower in the OSA group compared to the controls (1.67 (0.90–2.11) mg/L vs. 1.99 (1.53–3.51) mg/L, p = 0.04) after adjustment for age, gender, BMI and lipid profile. Plasma sLRP-1 concentrations were inversely related to age (r = −0.29), BMI (r = −0.35), cigarette pack years (r = −0.31), LDL-C (r = −0.34) and triglyceride levels (r = −0.27), TyG (r = −0.37) and AIP (r = −0.27) as well as to the oxygen desaturation index (ODI, r = −0.24, all p &lt, 0.05). BMI (p = 0.01) and ODI (p = 0.04) were independent predictors for low sLRP-1 levels. CALR did not differ significantly between the two groups (0.23 (0.17–0.34) ng/mL vs. 0.24 (0.20–0.36) ng/mL p = 0.76). We detected lower sLRP-1 levels in subjects with OSA which could contribute to metabolic abnormalities associated with this disease.

BackgroundMarfan syndrome (MFS) is a connective tissue disorder characterised by complex aortic pathology and a high prevalence of obstructive sleep apnoea (OSA). OSA produces intrathoracic transmural stresses that may accelerate aortic injury. The current study was designed to examine the associations between OSA risk and markers of aortic enlargement in MFS.MethodConsecutive patients with MFS were recruited at Johns Hopkins if they completed a STOP-BANG survey. Composite survey scores were categorised into those with low OSA risk (STOP-BANG ResultsOf the 89 participants studied, 28% had a high OSA risk and 32% had aortic grafts. Persons with high OSA risk had greater aortic root diameter (mm) (ß=4.13, SE=1.81, p=0.027) and aortic root dilatation (ß=2.80, SE=1.34, p=0.046) compared with those with low OSA risk . In addition, the odds of prior aortic root replacement was three times greater in those with high OSA risk compared with those with low OSA risk.ConclusionIn MFS, high OSA risk is associated with aortic enlargement and a threefold increased risk of having had prior aortic root replacement. These findings invite further exploration of the relationship between OSA and aortic disease in MFS, and studies to clarify whether targeted interventions for OSA might mitigate aortic disease progression in MFS.Registration numberIRB00157483.

Background and objectives: Sleep disturbances are frequently reported in children with brain tumours. The objective of our cross-sectional study was to systematically examine sleep in these children. We hypothesised that children with tumours involving the sleep-wake-regulatory areas have an altered sleep-wake-regulation. Methods: Sixty-one patients aged 0–18 years and with a diagnosis of a primary brain or cervical medullary tumour were included. They were categorised based upon tumour location into two groups – those affecting the sleep-wake regulatory regions, i.e. brain stem, basal forebrain, hypothalamus, thalamus, and posterior fossa compressing the brain stem and those that did not. Sleep history, questionnaire surveys, polysomnography, and multiple sleep latency test were used, as indicated clinically. Surveys included Pediatric Daytime Sleepiness Scale, Children's Sleep Habits Questionnaire, Strengths and Difficulties Questionnaire, and Pediatric Quality of Life Inventory, Multidimensional Fatigue Scale and Generic Core Scale. Results: Patients with tumours involving the sleep-wake regulatory areas were sleepier/more fatigued (p = 0.03). Sleep apnoea was observed in 86% of all the patients and comorbid narcolepsy in 8%, without group differences (p ≥ 0.12). Patients with tumours involving the sleep-wake-regulatory areas had more emotional problems (p = 0.04), were more affected by mental health problems (p < 0.001), and had poorer quality of life (p ≤ 0.03). Conclusions: Many children with brain tumours suffer from disturbed sleep, poor mental health, and low quality of life. We recommend that systematic sleep evaluation is included in their routine care along with psychological and social support.

Background There is lack of reliable and accurate methods to predict treatment outcomes of oral appliance (OA) treatment. Acoustic pharyngometry (AP) is a non-invasive technique to evaluate the volume and minimal cross-sectional area of the upper airway, which may prove useful to locate the optimal position of OAs. Objective This retrospective study aimed to evaluate the effect of applying AP to OA treatment of patients with obstructive sleep apnoea (OSA). Methods All patients (n = 244) treated with OAs following an AP protocol at two dental clinics between 2013 and 2018 were invited to participate. A total of 129 patients accepted the invitation, and 120 patients (75 men, 45 women) were included in the analyses. Mean baseline age, BMI and apnoea hypopnea index (AHI) were 59.1 ± 0.9 years, 27.8 ± 0.4 and 21.9 ± 1.1, respectively. Mean follow-up time was 318 ± 24 days. Results AHI at follow-up was 6.4 ± 0.7, resulting in a treatment success rate of 86.7% (≥50% reduction of baseline AHI). The number of failures ( 5 hours usage per night, when worn. Conclusion The AP protocol applied seems to contribute to the excellent effect of OA treatment in this study. Further research on the application of AP in OA treatment is necessary in order to clarify its possible beneficial contribution to improving OA therapy. publishedVersion

International audience; Aims Optimizing medical cardiac treatment for sleep apnoea (SA) in patients with chronic heart failure and reduced ejection fraction (HFrEF) is an expert Grade C recommendation based on six studies encompassing a total of 67 patients only. Whether sacubitril-valsartan (SV), a cornerstone of HFrEF medical treatment, impacts SA is unknown and requires evaluation.Methods and results The ENTRESTO-SAS trial is a six-centre, prospective, open-label real-life cohort study (NCT02916160). Ambulatory patients eligible for SV (i.e. HFrEF adults who remain symptomatic despite optimal treatment) were evaluated before and after 3 months of SV (including nocturnal ventilatory polygraphy); 118 patients were final analysed [median age was 66 (IQ 25-75 : 56-73) years, 81.4% male, 36.5% New York Heart Association III-IV, N-terminal pro-B-type natriuretic peptide level of 1564 (701-3376) ng/L, left ventricular ejection fraction of 30 (25-34)%, 60.7% ischaemic HFrEF, 97.5% initially treated with angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers, 83.9% with beta-blockers, 64.4% with mineralocorticoid receptor antagonists, and 74.6% with diuretics]. Three groups were defined according to initial central/obstructive apnoea-hypopnoea indices (AHIs): G1 (n = 49, AHI central ≥ 5/h and AHI obstructive < 15/h); G2 (n = 27, AHI obstructive ≥ 15/h); and G3 (n = 42, AHI central < 5/h and AHI obstructive < 15/h). At 3 months, the AHI (main predefined outcome) decreased significantly by À7.10/h (IQ 25-75 : À16.10 to 0.40; P < 0.001) in G1 + G2 without positive airway pressure treatment (45 patients, median initial AHI of 24.20 (IQ 25-75 : 16.40-43.50)/h). Of these, 24.4% presented an AHI decrease ≥50% and 37.78% had a final AHI < 15/h (tendency for improvement from an initial value of 20%: P = 0.0574). For G1 patients (n = 37), AHI significantly decreased from a median of 22.90 (16.00-43.50)/h to 19.20 (12.70-31.10)/h (P = 0.002). For G2 patients (n = 8), AHI decreased from a median of 30.10 (26.40-47.60)/h to 22.75 (14.60-36.90)/h (statistically non-significant, P = 0.059).Conclusions In this real-life population, SV treatment for 3 months in SA patients is associated with a significant decrease in AHI. These results support the current guidelines that recommend first an optimization of the HFrEF treatment in patients with HFrEF and central SA. A potential positive airway pressure sparing effect merits further investigation.

RationaleAdaptive servo ventilation (ASV) is contraindicated in patients with systolic heart failure (HF) who have a left ventricular ejection fraction (LVEF) below 45% and predominant central sleep apnoea (CSA). However, the effects of ASV in other HF subgroups have not been clearly defined.ObjectiveThe European, multicentre, prospective, observational cohort trial, FACE, evaluated the effects of ASV therapy on morbidity and mortality in patients with HF with sleep-disordered breathing (SDB); 3-month outcomes in patient subgroups defined using latent class analysis (LCA) are presented.MethodsConsecutive patients with HF with predominant CSA (±obstructive sleep apnoea) indicated for ASV were included from 2009 to 2018; the non-ASV group included patients who refused/were noncompliant with ASV. The primary endpoint was time to composite first event (all-cause death, lifesaving cardiovascular intervention or unplanned hospitalisation for worsening of chronic HF).Measurements and main resultsBaseline assessments were performed in 503 patients, and 482 underwent 3-month follow-up. LCA identified six discrete patient clusters characterised by variations in LVEF, SDB type, age, comorbidities and ASV acceptance. The 3- month rate of primary outcome events was significantly higher in cluster 1 patients (predominantly men, low LVEF, severe HF, CSA; 13.9% vs 1.5%–5% in other clusters, pConclusionFor the first time, our data identified homogeneous patient clusters representing clinically relevant subgroups relating to SDB management in patients with HF with different ASV usage, each with a different prognosis. This may improve patient phenotyping in clinical practice and allow individualisation of therapy.

Study objectives We initiated Hypoglossal Neurostimulation therapy (HGNS) at the Helsinki University Hospital in late 2014. Here, we report our experience. Methods We included all 15 HGNS patients. All patients had previously failed both CPAP and oral appliance therapy for sleep apnoea. Overnight polysomnography parameters were analysed before and at 1.5 years with HGNS. Results Mean +/- SD patient age was 53 +/- 6 years; 2 women and 13 men were included. Mean +/- SD efficient CPAP level was 11.4 +/- 3.4 cm H2O. Implantation technically succeeded in all patients. There were no significant changes of AHI and ODI4 after HGNS [median (quartile) 29.2/h (19.8-38.7) versus 30.1/h (15.6-52.6) and 15.0/h (5.9-20) versus 12.5/h (6.9-30.2) respectively]. Conclusion We did not observe significant changes in AHI and ODI4 indices with HGNS therapy. Larger multicentre randomised controlled trials are necessary before wider international use of HGNS.

Obstructive sleep apnoea (OSA) is highly prevalent and is a recognised risk factor for motor vehicle accidents (MVA). Effective treatment with continuous positive airway pressure has been associated with a normalisation of this increased accident risk. Thus, many jurisdictions have introduced regulations restricting the ability of OSA patients from driving until effectively treated. However, uncertainty prevails regarding the relative importance of OSA severity determined by the apnoea–hypopnoea frequency per hour and the degree of sleepiness in determining accident risk. Furthermore, the identification of subjects at risk of OSA and/or accident risk remains elusive. The introduction of official European regulations regarding fitness to drive prompted the European Respiratory Society to establish a task force to address the topic of sleep apnoea, sleepiness and driving with a view to providing an overview to clinicians involved in treating patients with the disorder. The present report evaluates the epidemiology of MVA in patients with OSA; the mechanisms involved in this association; the role of screening questionnaires, driving simulators and other techniques to evaluate sleepiness and/or impaired vigilance; the impact of treatment on MVA risk in affected drivers; and highlights the evidence gaps regarding the identification of OSA patients at risk of MVA.

Sleep apnoea is associated with negative outcomes following general anaesthesia. Current recommendations suggest using short-acting anaesthetic agents in preference to standard agents to reduce this risk, but there is currently no evidence to support this. This randomised controlled triple-blind trial tested the hypothesis that a combination of short-acting agents (desflurane-remifentanil) would reduce the postoperative impact of general anaesthesia on sleep apnoea severity compared with standard agents (sevoflurane-fentanyl). Sixty patients undergoing hip arthroplasty under general anaesthesia were randomised to anaesthesia with desflurane-remifentanil or sevoflurane-fentanyl. Respiratory polygraphy was performed before surgery and on the first and third postoperative nights. The primary outcome was the supine apnoea-hypopnoea index on the first postoperative night. Secondary outcomes were the supine apnoea-hypopnoea index on the third postoperative night, and the oxygen desaturation index on the first and third postoperative nights. Additional outcomes included intravenous morphine equivalent consumption and pain scores on postoperative days 1, 2 and 3. Pre-operative sleep study data were similar between groups. Mean (95%CI) values for the supine apnoea-hypopnoea index on the first postoperative night were 18.9 (12.7-25.0) and 21.4 (14.2-28.7) events.h -1 , respectively, in the short-acting and standard anaesthesia groups (p = 0.64). Corresponding values on the third postoperative night were 28.1 (15.8-40.3) and 38.0 (18.3-57.6) events.h -1 (p = 0.34). Secondary sleep- and pain-related outcomes were generally similar in the two groups. In conclusion, short-acting anaesthetic agents did not reduce the impact of general anaesthesia on sleep apnoea severity compared with standard agents. These data should prompt an update of current recommendations.

Obstructive sleep apnoea (OSA) is highly prevalent in atrial fibrillation (AF) patients and associated with reduced response to rhythm control strategies. However, there is no practical guidance on testing for OSA in AF patients and for OSA treatment implementation. We sought to evaluate current practices and identify challenges of OSA management in AF. A descriptive cross-sectional study was performed with a content-validated survey to evaluate OSA management in AF by healthcare practitioners. Survey review, editing, and dissemination occurred via the European Heart Rhythm Association and the Association of Cardiovascular Nursing and Allied Professions and direct contact with arrhythmia centres. In total, 186 responses were collected. OSA-related symptoms were ranked as the most important reason to test for OSA in AF patients. The majority (67.7%) indicated that cardiologists perform ‘ad-hoc’ referrals. Only 11.3% initiated systematic testing by home sleep test or respiratory polygraphy and in addition, 10.8% had a structured OSA assessment pathway in place at the cardiology department. Only 6.7% of the respondents indicated that they test >70% of their AF patients for OSA as a component of rhythm control therapy. Various barriers were reported: no established collaboration between cardiology and sleep clinic (35.6%); lack in skills and knowledge (23.6%); lack of financial (23.6%) and personnel-related resources (21.3%). Structured testing for OSA occurs in the minority of AF patients. Centres apply varying methods. There is an urgent need for increased awareness and standardized pathways to allow OSA testing and treatment integration in the management of AF.

Purpose To study changes in lung function among individuals with a risk of obstructive sleep apnoea (OSA), and if asthma affected this relationship. Methods We used data from the European Community Respiratory Health Survey II and III, a multicentre general population study. Participants answered questionnaires and performed spirometry at baseline and 10-year follow-up (n = 4,329 attended both visits). Subjects with high risk for OSA were identified from the multivariable apnoea prediction (MAP) index, calculated from BMI, age, gender, and OSA symptoms at follow-up. Asthma was defined as having doctor’s diagnosed asthma at follow-up. Primary outcomes were changes in forced expiratory volume in 1 s (FEV1) and forced vital capacity (FVC) from baseline to follow-up. Results Among 5108 participants at follow-up, 991 (19%) had a high risk of OSA based on the MAP index. Participants with high OSA risk more often had wheeze, cough, chest tightness, and breathlessness at follow-up than those with low OSA risk. Lung function declined more rapidly in subjects with high OSA risk (low vs high OSA risk [mean ± SD]: FEV1 = − 41.3 ± 24.3 ml/year vs − 50.8 ± 30.1 ml/year; FVC = − 30.5 ± 31.2 ml/year vs − 45.2 ± 36.3 ml/year). Lung function decline was primarily associated with higher BMI and OSA symptoms. OSA symptoms had a stronger association with lung function decline among asthmatics, compared to non-asthmatics. Conclusion In the general population, a high probability of obstructive sleep apnoea was related to faster lung function decline in the previous decade. This was driven by a higher BMI and more OSA symptoms among these subjects. The association between OSA symptoms and lung function decline was stronger among asthmatics.

Background: The prevalence of obstructive sleep apnoea syndrome (OSAS) keeps on rising. Daytime sleepiness resulting from fragmented sleep is the prime symptom, and obesity the major risk factor for OSAS. Quality of life with OSAS is often affected by depressive symptoms and anxiety. Nasal continuous positive airway pressure (CPAP) therapy reduces daytime sleepiness, but the results on the effect on mood, physical activity, and weight are controversial especially on long-term therapy. Purpose of this study was to evaluate these factors and predictors of weight gain during long-term CPAP therapy. Methods: Consecutive patients (n = 223), referred to sleep study with suspected OSAS, were enrolled. Patients underwent a cardiorespiratory polygraphy at baseline and a battery of questionnaires was completed, both at baseline, and after three years of follow-up. Total of 149 (67%; M 65, F 84) patients completed the follow-up. Of the 149 patients, 76 (51.0%; M 32, F 44) used CPAP. Results: In this study, depressive symptoms, anxiety, and sleepiness were alleviated during CPAP therapy. However, therapy did not have an influence on cravings of different food categories, or exercise habits and exercise duration. From the various factors studied, solely higher adherence to CPAP therapy was associated with weight gain. Conclusions: This research provides further evidence that long-term CPAP therapy in patients with OSAS not only decreases sleepiness and improves sleep quality but could also alleviate depressive symptoms and anxiety. In addition, our study reinforces that CPAP therapy alone is not sufficient for weight management in patients with OSAS. Regardless of comprehensive battery of questionnaires, we were unable to establish markers predicting weight gain during therapy. We advise on life-style counselling and weight management program to all patients with obesity on CPAP therapy. publishedVersion

Background: The impact of removing the upper airway lymphoid tissue and in particular, tonsillectomy, in adults with OSA has not been demonstrated in large populations. Aims: To compare the severity of OSA and the prevalence of cardiovascular, metabolic and respiratory co-morbidities between patients with OSA who had undergone previous tonsillectomy and those who had not. Methods: The 19,711 participants in this study came from the European sleep apnea database (ESADA) which comprises data from unselected adult patients aged 18–80 years with a history of symptoms suggestive of OSA referred to sleep centers throughout Europe. Results: There were no differences between the two groups in terms of sex ratio and age (146 patients with previous tonsillectomy vs. 19565 patients without). Patients who had undergone tonsillectomy had a lower body mass index (29.3 ± 5.2 kg/m2 vs 32.2 ± 6.6 kg/m2, p < 0.001), lower subjective sleep latency (17.1 ± 17.8 min vs 25.5 ± 30.4 min, p = 0.001), lower ODI (15.7 ± 18.3 events/hour vs 30.7 ± 26.1 events/hour, p < 0.001), and SpO2, European Respiratory Society, ERS, The ESADA network has previously received support from the European Union COST action B26 and the European Respiratory Society. We gratefully acknowledge unrestricted seeding grants from ResMed Inc and Philips Respironics Inc. for establishment of the organisation and the database. Excellent technical assistance in terms of centre monitoring and database maintenance was provided by Ann-Christin Lundquist, RN and Jeanette Norum, RN.

BackgroundObstructive sleep apnoea (OSA) presents a major healthcare challenge with current UK data suggesting that only 22% of individuals have been diagnosed and treated. Promoting awareness and improving access to diagnostics are fundamental in addressing these missing cases and the recognised complications associated with untreated OSA. Diagnosis usually occurs in secondary care with data from our trust revealing long wait times to undertake tests, reach a diagnosis and start treatment. This places a considerable time and emotional burden on the patient and a financial and logistical burden on the hospital.MethodsWe introduced an integrated community-based pathway for the diagnosis of OSA. This comprised a monthly clinic run from within a local general practice (GP) supported by a ‘virtual multidisciplinary team’ run by the hospital specialist team. Prospective collection of process, outcome and patient satisfaction data was compared with traditional hospital-based pathway data collected retrospectively.SettingA central London teaching hospital and GPs within a local commissioning neighbourhood.ResultsBetween January 2018 and February 2019, 70 were patients referred and managed along the community pathway. Compared with the hospital pathway, data demonstrated a significant reduction in the time taken: from referral to perform a sleep test (29 vs 181 days, pConclusionAn integrated community-based pathway results in more timely diagnosis of OSA within a local setting while maintaining specialist input from the hospital team. It is favoured by patients and can reduce unnecessary appointments in secondary care.

Background: Sleep disorders are associated with overweight and obese children, and could decrease life quality with limitations to normal daily activities. The purpose of the study is to describe the prevalence of sleep disorders in a cohort of overweight/obese children using respiratory polygraphy. Methods: A descriptive cross-sectional study was conducted in Granada (Spain) on a sample of 98 children with overweight or obesity. The presence of sleep disorders was determined by respiratory polygraphy. Results: Regarding apnoea&ndash, hypopnea-index (AHI) results, 44% of affected children had severe sleep apnoea&ndash, hypopnea syndrome (SAHS), and the remaining 56% had a mild form of the disorder. With respect to oxygen-desaturation index, 56% of the same group had severe SAHS, 32% had mild SAHS, and the remaining 12% did not suffer from SAHS. Among participants, average scores of 13.8 obstructive apnoea, 7.7 central apnoea, and 13.6 hypopnoea were recorded. Conclusions: Respiratory polygraphy can provide conclusive results in the diagnosis of SAHS in overweight/obese children. Interventional programmes designed and implemented to reduce overweight and obesity can improve quality of sleep and life in children.

Summary Sleep apnoea is associated with negative outcomes following general anaesthesia. Current recommendations suggest using short‐acting anaesthetic agents in preference to standard agents to reduce this risk, but there is currently no evidence to support this. This randomised controlled triple‐blind trial tested the hypothesis that a combination of short‐acting agents (desflurane‐remifentanil) would reduce the postoperative impact of general anaesthesia on sleep apnoea severity compared with standard agents (sevoflurane‐fentanyl). Sixty patients undergoing hip arthroplasty under general anaesthesia were randomised to anaesthesia with desflurane‐remifentanil or sevoflurane‐fentanyl. Respiratory polygraphy was performed before surgery and on the first and third postoperative nights. The primary outcome was the supine apnoea‐hypopnoea index on the first postoperative night. Secondary outcomes were the supine apnoea‐hypopnoea index on the third postoperative night, and the oxygen desaturation index on the first and third postoperative nights. Additional outcomes included intravenous morphine equivalent consumption and pain scores on postoperative days 1, 2 and 3. Pre‐operative sleep study data were similar between groups. Mean (95%CI) values for the supine apnoea‐hypopnoea index on the first postoperative night were 18.9 (12.7–25.0) and 21.4 (14.2–28.7) events.h−1, respectively, in the short‐acting and standard anaesthesia groups (p = 0.64). Corresponding values on the third postoperative night were 28.1 (15.8–40.3) and 38.0 (18.3–57.6) events.h−1 (p = 0.34). Secondary sleep‐ and pain‐related outcomes were generally similar in the two groups. In conclusion, short‐acting anaesthetic agents did not reduce the impact of general anaesthesia on sleep apnoea severity compared with standard agents. These data should prompt an update of current recommendations.

Purpose of review Diagnosis of sleep apnoea was performed in sleep laboratories with polysomnography. This requires a room with supervision and presence of technologists and trained sleep experts. Today, clinical guidelines in most countries recommend home sleep apnoea testing with simple systems using six signals only. If criteria for signal quality, recording conditions, and patient selection are considered, then this is a reliable test with high accuracy. Recent findings Recently diagnostic tools for sleep apnoea diagnosis become even more simple: smartwatches and wearables with smart apps claim to diagnose sleep apnoea when these devices are tracking sleep and sleep quality as part of new consumer health checking. Alternative and new devices range from excellent diagnostic tools with high accuracy and full validation studies down to very low-quality tools which only result in random diagnostic reports. Due to the high prevalence of sleep apnoea, even a random diagnosis may match a real disorder sometimes. Summary Until now, there are no metrics established how to evaluate these alternative algorithms and simple devices. Proposals for evaluating smartwatches, smartphones, single-use sensors, and new algorithms are presented. New assessments may help to overcome current limitations in sleep apnoea severity metrics. VIDEO ABSTRACT: http://links.lww.com/COPM/A28.

Objectives Hearing impairment (HI) is a leading impairment worldwide, and identifying modifiable risk factors of HI may have major public health implications. The aim of this study was to investigate the association between obstructive sleep apnoea (OSA) and HI.Design Observational longitudinal study (the Paris Prospective Study 3).Setting Population-based.Participants Volunteers aged 50-75 years and consulting at a preventive medical centre were included between 2008 and 2012. 6797 participants were included in the present analysis.Main outcome measures Audiometry testing was performed in both ears in all participants, and HI was defined by a pure-tone average (PTA) >25 decibels (dB) hearing level in the better ear.Results Obstructive sleep apnoea (estimated by the Berlin questionnaire) was present in 18.6% (n = 1267) and HI in 13.9% (n = 947) of the participants. Mean age was 59.5 years (SD 6.2) and 63.5% were male (n = 4317). In multiple logistic regression modelling, OSA was significantly associated with a 1.21-increased odds of HI (95% confidence interval 1.01-1.44). Several sensitivity analyses supported this finding.Conclusion Obstructive sleep apnoea is associated with a 21% increased odds of HI. These results support active screening of HI in subjects with OSA, and future studies should evaluate whether the treatment of OSA can delay the onset of HI.

BackgroundUse of non-invasive ventilation (NIV) in adolescents with Duchenne muscular dystrophy (DMD) has increased with concomitant extended survival.AimTo describe lung function (LF) changes with NIV in adolescents with DMD and to assess differences betweenSteroid UsersandSteroid Naïvesubjects.MethodA retrospective cohort of adolescents with DMD initiating NIV over 10 years was conducted. Serial LF before and after NIV initiation was collated. Use of systemic glucocorticosteroids, adherence to NIV and presence of cardiac disease were assessed.ResultsTwenty-nine men started NIV, median age 14.66 years (IQR 2.35, 10.47–17.96). Nine wereSteroid Usersand eight wereSteroid Naïve. Indications for NIV were apnoea–hypopnoea index >5 and/or nocturnal hypoventilation. LF is better (forced vital capacity (FVC) z-score −3.26 vs −5.41, p < 0.02) and decline slower (FVC z-score −0.58 per annum (pa) vs −0.68 pa, pSteroid Userscompared withSteroid Naïvesubjects. Following NIV initiation, FVC z-score decline slowed for the whole (−0.72 pa (95% CI −0.79 to 0.64) to −0.46 pa (95% CI −0.54 to 0.38) p < 0.001) andSteroid Naïvegroups (−0.74 (95% CI −0.85 to 0.63) to −0.44 pa (95% CI −0.56 to 0.32) p < 0.001) but accelerated in theSteroid Usergroup (−0.56 (95% CI −0.70 to 0.42) to −0.75 pa (95% CI −0.89 to 0.61) p < 0.001). Adherence to NIV and cardiac disease did not impact decline.ConclusionOverall, LF decline is reduced on NIV.Steroid Naïvepatients have lower LF and faster decline, which slows following NIV initiation. An accelerated LF decline was seen on NIV inSteroid Userswhich requires further prospective research.

The treatment of sleep disorders has been strongly impacted by the COVID-19 pandemic. When the lockdown is over, resumption of usual patient care will require precautions to limit the risk of contamination for patients and caregivers. In this document, the French Association of Otorhinolaryngology and Sleep disorders (AFSORL) and the French Society of Otorhinolaryngology (SFORL) put forward a summary of the measures for continuing the treatment of sleep apnoea syndrome in these new practice conditions. Emphasis is placed on teleconsultation, methods of nocturnal sleep studies, the conditions for treatment by continuous positive airway pressure (CPAP) ventilation, and the postponement of more invasive treatments.

Background Obesity hypoventilation syndrome (OHS) is treated with either non-invasive ventilation (NIV) or CPAP, but there are no long-term cost-effectiveness studies comparing the two treatment modalities. Objectives We performed a large, multicentre, randomised, open-label controlled study to determine the comparative long-term cost and effectiveness of NIV versus CPAP in patients with OHS with severe obstructive sleep apnoea (OSA) using hospitalisation days as the primary outcome measure. Methods Hospital resource utilisation and within trial costs were evaluated against the difference in effectiveness based on the primary outcome (hospitalisation days/year, transformed and non-transformed in monetary term). Costs and effectiveness were estimated from a log-normal distribution using a Bayesian approach. A secondary analysis by adherence subgroups was performed. Results In total, 363 patients were selected, 215 were randomised and 202 were available for the analysis. The median (IQR) follow-up was 3.01 (2.91-3.14) years for NIV group and 3.00 (2.92-3.17) years for CPAP. The mean (SD) Bayesian estimated hospital days was 2.13 (0.73) for CPAP and 1.89 (0.78) for NIV. The mean (SD) Bayesian estimated cost per patient/year in the NIV arm, excluding hospitalisation costs, was €2075.98 (91.6), which was higher than the cost in the CPAP arm of €1219.06 (52.3); mean difference €857.6 (105.5). CPAP was more cost-effective than NIV (99.5% probability) because longer hospital stay in the CPAP arm was compensated for by its lower costs. Similar findings were observed in the high and low adherence subgroups. Conclusion CPAP is more cost-effective than NIV; therefore, CPAP should be the preferred treatment for patients with OHS with severe OSA. Trial registration number NCT01405976, Instituto de Salud Carlos III (Fondo de Investigaciones Sanitarias, Ministerio de Sanidad y Consumo) PI050402, Spanish Respiratory Foundation 2005 (FEPAR) and Air Liquide Spain.

Obejctive Obstructive sleep apnoea (OSA) increases left ventricular transmural pressure more than central sleep apnoea (CSA) owing to negative intrathoracic pressure swings. We tested the hypothesis that the severity of OSA, and not CSA, is therefore associated with spheric cardiac remodelling after acute myocardial infarction. Methods This sub-analysis of a prospective observational study included 24 patients with acute myocardial infarction who underwent primary percutaneous coronary intervention. Spheric remodelling, calculated according to the sphericity index, was assessed by cardiac magnetic resonance imaging at baseline and 12 weeks after acute myocardial infarction. OSA and CSA [apnoea-hypopnoea index (AHI) ≥ 5/hour] were diagnosed by polysomnography. Results Within 12 weeks after acute myocardial infarction, patients with OSA exhibited a significant increase in systolic sphericity index compared to patients without sleep-disordered breathing (no SDB) and patients with CSA (OSA vs. CSA vs. no SDB: 0.05 ± 0.04 vs. 0.01 ± 0.04 vs. − 0.03 ± 0.03, p = 0.002). In contrast to CSA, the severity of OSA was associated with an increase in systolic sphericity index after accounting for TIMI-flow before percutaneous coronary intervention, infarct size, pain-to-balloon-time and systolic blood pressure [OSA: B (95% CI) 0.443 (0.021; 0.816), p = 0.040; CSA: 0.193 (− 0.134; 0.300), p = 0.385]. Conclusion In contrast to CSA and no SDB, OSA is associated with spheric cardiac remodelling within the first 12 weeks after acute myocardial infarction. Data suggest that OSA-related negative intrathoracic pressure swings may contribute to this remodelling after acute myocardial infaction. Graphic abstract

Background and objective: Obstructive sleep apnoea (OSA) and dyslipidaemia are independent risk factors for cardiovascular disease. This study investigates the association between OSA and plasma lipid concentrations in patients enrolled in the European Sleep Apnea Database (ESADA) cohort. Methods: The cross-sectional analysis included 8592 patients without physician-diagnosed hyperlipidaemia or reported intake of a lipid-lowering drug (age 50.1 ± 12.7 years, 69.1% male, BMI: 30.8 ± 6.6 kg/m2, mean apnoea–hypopnoea index (AHI): 25.7 ± 25.9 events/h). The independent relationship between measures of OSA (AHI, oxygen desaturation index (ODI), mean and lowest oxygen saturation) and lipid profile (total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C) and fasting triglycerides (TG)) was determined by means of general linear model analysis. Results: There was a dose response relationship between TC and ODI (mean ± SE (mg/dL): 180.33 ± 2.46, 184.59 ± 2.42, 185.44 ± 2.42 and 185.73 ± 2.44; P < 0.001 across ODI quartiles I–IV). TG and LDL concentrations were better predicted by AHI than by ODI. HDL-C was significantly reduced in the highest AHI quartile (mean ± SE (mg/dL): 48.8 ± 1.49 vs 46.50 ± 1.48; P = 0.002, AHI quartile I vs IV). Morbid obesity was associated with lower TC and higher HDL-C values. Lipid status was influenced by geographical location with the highest TC concentration recorded in Northern Europe. Conclusion: OSA severity was independently associated with cholesterol and TG concentrations.

The treatment of choice for obstructive sleep apnoea (OSA) is continuous positive airway pressure therapy (CPAP). Since its introduction in clinical practice, CPAP has been used in various clinical conditions with variable and heterogeneous outcomes. In addition to the well-known effects on the upper airway CPAP impacts on intrathoracic pressures, haemodynamics and blood pressure (BP) control. However, short- and long-term effects of CPAP therapy depend on multiple variables which include symptoms, underlying condition, pressure used, treatment acceptance, compliance and usage. CPAP can alter long-term cardiovascular risk in patients with cardiorespiratory conditions. Furthermore, the effect of CPAP on the awake patient differs from the effect on the patients while asleep, and this might contribute to discomfort and removal of the use interface. The purpose of this review is to highlight the physiological impact of CPAP on the cardiorespiratory system, including short-term benefits and long-term outcomes.

IntroductionThe main treatment for sleep apnoeas and hypopnoeas syndrome (SAHS) is continuous positive airway pressure (CPAP). However, patients sometimes do not adhere to the treatment protocol. Supplementary and complementary therapies have appeared as alternatives. Some of the therapies which are especially important are those related to myofunctional (MFT) and postural therapy (PT), as all of them are non-invasive, and their application is simpler than that of CPAP. We aim to present a protocol for a systematic review and meta-analysis for investigating new SAHS treatments, including the protocols and frequency of use and the effects they have on patient signs, symptoms and quality of life.Methods and analysisThe literature search will be conducted using the Cochrane, Web of Science, Medline (via PubMed) and Scopus databases, from January 2020 to December 2020. All types of studies written in English and Spanish that investigate the use of alternative SAHS treatments related to MFT, or more importantly, the combination of MFT and PRT, will be selected. To evaluate their quality, the Critical Appraisal Checklist for Analytical Cross-Sectional will be applied. The primary factor valued in the studies will be the inclusion of MFT and PT reeducation in the treatment. Subgroup analyses will be carried out evaluating the specific type of treatments chosen and the improvements or deteriorations in the level of health and quality of life in the patients. Finally, several patient-related outcomes, namely sleep quality, quality of life and sleep Apnoeas and Hypoapnoeas Index, will be examined.Ethics and disseminationIn this case, ethical approval is not necessary. The data used in the review will be exclusively obtained from published studies, implying there are no privacy concerns. The information obtained will be relevant to understand if the new treatments applied in SAHS are effective, and if postural and MFT therapy used together can be considered an appropriate approach to treat this disease.The results will be published in a peer-reviewed journal.

BackgroundContinuous positive airway pressure (CPAP) mask renewal policies vary inside and between countries. There are no independent studies on the optimal mask renewal frequency. We aimed to evaluate CPAP mask function over time in a real-life clinical setting, and to compare the results against current renewal policies.MethodsDaily performance data of 1846 CPAP masks (65% nasal, 22% nasal pillows, 12% oronasal) were recorded from 450 participants (68% male, mean age 59 years) with obstructive sleep apnoea. The unintentional leak, Apnoea-Hypopnoea Index (CPAP-AHI) and usage data were exported from the CPAP device.ResultsOf 656 324 nights of CPAP usage, the mean renewal time was 497 days (SD 327), mean leak 5.7 L/min (SD 8.1) and CPAP-AHI 3.8 events/h (SD 3.6). The difference in mean leak between one (5.2 L/min, SD 7.5), 12 (6.0 L/min, SD 10.2) and 24 months (5.8 L/min, SD 7.5) was minimal (p=0.59). Mean CPAP-AHI remained normal and unchanged in nasal masks and pillows up to 30 months, and was highest in oronasal masks. Different mask manufacturers performed similarly. Masks’ daily or total usage did not affect the results. Shifting the mask renewal policy to 24 months could reduce the mask-related cost up to 50%–88%.ConclusionsNasal masks and pillows could be used at least 2 years without significant changes in unintentional leak and CPAP-AHI. We suggest updating the mask renewal policies of nasal masks and pillows; results on oronasal masks and other manufacturers CPAP devices need further verification.

Objectives The aim of this study was to demonstrate in a prospective multi-centre study that Barbed Reposition Pharyngoplasty (BRP) procedure is safe and effective in management of obstructive sleep apnea/hypopnea syndrome (OSAHS) patients. Design prospective study. Setting multicenter study. Participants patients suffering from obstructive sleep apnea. Main outcomes measures values of post-operative apnea-hypopnea index(AHI), oxygen desaturation index (ODI), epworth sleepiness scale (ESS). Results 111 BRP procedures standing alone or as a part of multilevel surgery for OSAHS, performed between January and September 2016, were analyzed in 15 different centers. The average hospitalization period was 2.5 ± 0.5 days. The mean patient age was 46.3 ± 10.5 years. The average BMI at the time of the procedure was 27.9 ± 3.2 and the majority of the patients were men (83%). The mean pre-operative and post-operative apnea/hypopnea index was 33.4 ± 19.5 and 13.5 ± 10.3, respectively (p < 0.001). The mean pre-operative and post-operative epworth sleepiness scale score was 10.2 ± 4.5 and 6.1 ± 3.6, respectively (p < 0.001). The mean pre- and post-operative oxygen desaturation index was 29.6 ± 20.7 and 12.7 ± 10.8, respectively (p < 0.001). Conclusions Patients undergoing BRP standing alone or as part of a multilevel approach for the treatment of OSAHS have a reasonable expectation for success with minimal morbidity. This article is protected by copyright. All rights reserved.

The surgical treatment of obstructive sleep apnoea in patients who are non-compliant with continuous positive airway pressure therapy still represents a valid alternative. In recent years, the multilevel approach is becoming more diffuse in routine surgical practice, especially since the introduction of transoral robotic surgery. Barbed reposition pharyngoplasty in multilevel robotic surgery for OSA may represent a valid option to surgically approach the soft palate. Herein, we describe the technique and preliminary results of our experience.Il trattamento chirurgico delle apnee ostruttive in sonno rappresenta una valida alternativa per i pazienti non complianti al ventilatore CPAP. Negli ultimi anni, l’approccio chirurgico multilivello sta divenendo pratica comune, soprattutto dall’introduzione della chirurgia robotica. La Barbed Reposition Pharyngoplasty nella chirurgia robotica multilivello per OSA potrebbe rappresentare una valida opzione per il trattamento del palato molle. In questo lavoro descriviamo la tecnica e risultati preliminari della nostra esperienza.

Aim The burden of referrals to investigate sleep disorders has escalated considerably. In order to address this, the feasibility of a nurse-led sleep disorder clinic was investigated. Methods Sleep referrals were stratified on the basis of information contained within the primary care referral, and appropriate home-based sleep studies arranged if obstructive sleep apnoea was considered the most likely working diagnosis. Selected patients were started on continuous positive airway pressure treatment if deemed appropriate. Education was almost exclusively provided by specialist nursing staff or by means of validated information by the British Lung Foundation. Results Eighty patients were included in the respiratory nurse-led sleep service. Feedback from the patient questionnaire was positive and 59 patients were managed without requirement to attend consultant-led outpatient services. Non-sleep breathing disorders as the reason for daytime somnolence, and patients requiring referral to tertiary services, were identified. Conclusion Developing a respiratory nurse-led sleep service is adequate to identify non-sleep breathing disorders, is fit for purpose, functions broadly in accordance with American Sleep Society guidelines, and is well received by patients.

Tracheostomy decannulation has always been considered a procedure with an attendant risk, especially in patients with a reduced upper airway diameter as is commonly observed in the obstructive sleep apnoea (OSA) population. We report on 4 cases where transoral robotic surgery (TORS) helped in the management of long-term cannulated patients. The aims of our paper are: 1. To demonstrate how the otolaryngology team can help identify patients at high risk for decannulation failure; and 2. To demonstrate how TORS may aid in the decannulation process of patients at high risk for failure due to severe tongue base hypertrophy. From our experience, TORS appears to offer an effective option to aid in the decannulation of patients with a severe hypertrophy of the base of tongue and floppy epiglottis.La decannulazione è sempre stata considerata una procedura con un certo grado di rischio, specie nei pazienti con ridotti diametri delle via aeree, come nel caso della sindrome delle apnee ostruttive (OSA). Presentiamo 4 casi nei quali la chirurgia robotica transorale (TORS) ha permesso un appropriato management di pazienti tracheotomizzati da divers mesi. Gli obiettivi del nostro lavoro sono: 1. Dimostrare come il team otorinolaringoiatrico possa favorire il riconoscimento di pazienti ad alto rischio di decannulazione inefficace e 2. Evidenziare il ruolo nella TORS nel trattamento dell’ipertrofia della base della lingua, responsabile dell’ostruzione delle vie aeree superiori. Dalla nostra esperienza la TORS appare una tecnica efficace nella decannulazione di pazienti affetti da ipertrofia della base della lingua e da epiglottide flottante.