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Sleep disordered breathing causes repetitive episodes of nocturnal hypoxemia, sympathetic nervous activation, and cortical arousal, often associated with excessive daytime sleepiness. Sleep disordered breathing is common in people with, or at risk of, cardiovascular (CV) disease including those who are obese or have hypertension, coronary disease, heart failure, or atrial fibrillation. Current therapy of obstructive sleep apnea includes weight loss (if obese), exercise, and positive airway pressure (PAP) therapy. This improves daytime sleepiness. Obstructive sleep apnea is associated with increased CV risk, but treatment with PAP in randomized trials has not been shown to improve CV outcome. Central sleep apnea (CSA) is not usually associated with daytime sleepiness in heart failure or atrial fibrillation and is a marker of increased CV risk, but PAP has been shown to be harmful in 1 randomized trial. The benefits of better phenotyping, targeting of higher-risk patients, and a more personalized approach to therapy are being explored in ongoing trials.

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.

What you need to know Obstructive sleep apnoea/hypopnoea syndrome (OSAHS) affects around 5% of adults in the UK, while obesity hypoventilation syndrome (OHS) is estimated to affect 0.3-0.4% of the general population.1 In addition to sleepiness, OSAHS may present with a range of symptoms including insomnia and difficulties concentrating, and it can lead to hypertension and exacerbate pre-existing cardiovascular disease. People with OHS are at higher risk of cardiovascular complications and have higher mortality compared with non-obese people.2 This article summarises the most recent recommendations from the National Institute for Health and Care Excellence (NICE) guideline for obstructive sleep apnoea/hypopnoea syndrome and obesity hypoventilation syndrome in adults (over 16 years old).3 The guideline, published in August 2021, covers diagnosis and management of OSAHS, OHS, and COPD-OSAHS overlap syndrome. This guideline summary discusses only selected recommendations on OSAHS and OHS, focusing on those most relevant to primary care. NICE recommendations are based on systematic reviews of best available evidence and explicit consideration of cost effectiveness. When minimal evidence is available, recommendations are based on the guideline committee’s experience and opinion of what constitutes good practice. Evidence levels for the recommendations are given in italic in square brackets. ### Obstructive sleep apnoea/hypopnoea syndrome (OSAHS) In this condition the upper airway is narrowed or closes during sleep when muscles relax, causing under-breathing (hypopnoea) or stopping breathing …

This editorial describes the ERS CRC programme, which addresses research areas across all major respiratory disease domains. It explains how the ERS Research Agency supports the CRCs to obtain external funding and ensures links with other ERS activities.https://bit.ly/2WHIQPa

Background: Both continuous positive airway pressure (CPAP) and high-flow nasal oxygenation (HFNO) have been recommended for acute respiratory failure in COVID-19. However, uncertainty exists regarding effectiveness and safety. Methods: In the Recovery-Respiratory Support multi-center, three-arm, open-label, adaptive, randomized controlled trial, adult hospitalized patients with acute respiratory failure due to COVID-19, deemed suitable for treatment escalation, were randomly assigned to receive CPAP, HFNO, or conventional oxygen therapy. Comparisons were made between each intervention and conventional oxygen therapy. The primary outcome was a composite of tracheal intubation or mortality within 30-days. Results: Over 13-months, 1272 participants were randomized and analysed (380 (29.9%) CPAP; 417 (32.8%) HFNO; 475 (37.3%) conventional oxygen therapy). The need for tracheal intubation or mortality within 30-days was lower in the CPAP group (CPAP 137 of 377 participants (36.3%) vs conventional oxygen therapy 158 of 356 participants (44.4%); unadjusted odds ratio 0.72; 95% CI 0.53 to 0.96, P=0.03). There was no difference between HFNO and conventional oxygen therapy (HFNO 184 of 414 participants (44.4%) vs conventional oxygen therapy 166 of 368 participants (45.1%); unadjusted odds ratio 0.97; 95% CI 0.73 to 1.29, P=0.85). Conclusions: CPAP, compared with conventional oxygen therapy, reduced the composite outcome of intubation or death within 30 days of randomisation in hospitalized adults with acute respiratory failure due to COVID-19. No effect was observed with the use of HFNO. (Funded by the UK National Institute for Health Research; ISRCTN 16912075).

BackgroundBoth continuous positive airway pressure (CPAP) and high-flow nasal oxygenation (HFNO) have been recommended for acute respiratory failure in COVID-19. However, uncertainty exists regarding effectiveness and safety.MethodsIn the Recovery-Respiratory Support multi-center, three-arm, open-label, adaptive, randomized controlled trial, adult hospitalized patients with acute respiratory failure due to COVID-19, deemed suitable for treatment escalation, were randomly assigned to receive CPAP, HFNO, or conventional oxygen therapy. Comparisons were made between each intervention and conventional oxygen therapy. The primary outcome was a composite of tracheal intubation or mortality within 30-days.ResultsOver 13-months, 1272 participants were randomized and included in the analysis (380 (29.9%) CPAP; 417 (32.8%) HFNO; 475 (37.3%) conventional oxygen therapy). The need for tracheal intubation or mortality within 30-days was lower in the CPAP group (CPAP 137 of 377 participants (36.3%) vs conventional oxygen therapy 158 of 356 participants (44.4%); unadjusted odds ratio 0.72; 95% CI 0.53 to 0.96, P=0.03). There was no difference between HFNO and conventional oxygen therapy (HFNO 184 of 414 participants (44.4%) vs conventional oxygen therapy 166 of 368 participants (45.1%); unadjusted odds ratio 0.97; 95% CI 0.73 to 1.29, P=0.85).ConclusionsCPAP, compared with conventional oxygen therapy, reduced the composite outcome of intubation or death within 30 days of randomisation in hospitalized adults with acute respiratory failure due to COVID-19. There was no effect observed, compared with conventional oxygen therapy, with the use of HFNO.(Funded by the UK National Institute for Health Research; ISRCTN 16912075).

BackgroundContinuous positive airways pressure (CPAP) and high-flow nasal oxygen (HFNO) are considered ‘aerosol-generating procedures’ in the treatment of COVID-19.ObjectiveTo measure air and surface environmental contamination with SARS-CoV-2 virus when CPAP and HFNO are used, compared with supplemental oxygen, to investigate the potential risks of viral transmission to healthcare workers and patients.Methods30 hospitalised patients with COVID-19 requiring supplemental oxygen, with a fraction of inspired oxygen ≥0.4 to maintain oxygen saturation ≥94%, were prospectively enrolled into an observational environmental sampling study. Participants received either supplemental oxygen, CPAP or HFNO (n=10 in each group). A nasopharyngeal swab, three air and three surface samples were collected from each participant and the clinical environment. Real-time quantitative polymerase chain reaction analyses were performed for viral and human RNA, and positive/suspected-positive samples were cultured for the presence of biologically viable virus.ResultsOverall 21/30 (70%) participants tested positive for SARS-CoV-2 RNA in the nasopharynx. In contrast, only 4/90 (4%) and 6/90 (7%) of all air and surface samples tested positive (positive for E and ORF1a) for viral RNA respectively, although there were an additional 10 suspected-positive samples in both air and surfaces samples (positive for E or ORF1a). CPAP/HFNO use or coughing was not associated with significantly more environmental contamination than supplemental oxygen use. Only one nasopharyngeal sample was culture positive.ConclusionsThe use of CPAP and HFNO to treat moderate/severe COVID-19 did not appear to be associated with substantially higher levels of air or surface viral contamination in the immediate care environment, compared with the use of supplemental oxygen.

The reported effect of CPAP on cardiovascular outcomes in sleep apnoea should be interpreted with caution and several factors must be considered before definite conclusions can be drawnhttps://bit.ly/3lLQG4d

BackgroundContinuous positive airways pressure (CPAP) and high-flow nasal oxygen (HFNO) are considered ‘aerosol-generating procedures’ (AGPs) in the treatment of COVID-19. We aimed to measure air and surface environmental contamination of SARS-CoV-2 virus when CPAP and HFNO were used, compared with supplemental oxygen, to investigate the potential risks of viral transmission to healthcare workers and patients.Methods30 hospitalised patients with COVID-19 requiring supplemental oxygen, with a fraction of inspired oxygen ≥0.4 to maintain oxygen saturations ≥94%, were prospectively enrolled into an observational environmental sampling study. Participants received either supplemental oxygen, CPAP or HFNO (n=10 in each group). A nasopharyngeal swab, three air and three surface samples were collected from each participant and the clinical environment. RT qPCR analyses were performed for viral and human RNA, and positive/suspected-positive samples were cultured for the presence of biologically viable virus.ResultsOverall 21/30 (70%) of participants tested positive for SARS-CoV-2 RNA in the nasopharynx. In contrast, only 4/90 (4%) and 6/90 (7%) of all air and surface samples tested positive (positive for E and ORF1a) for viral RNA respectively, although there were an additional 10 suspected-positive samples in both air and surfaces samples (positive for E or ORF1a). CPAP/HFNO use or coughing was not associated with significantly more environmental contamination. Only one nasopharyngeal sample was culture positive.ConclusionsThe use of CPAP and HFNO to treat moderate/severe COVID-19 was not associated with significantly higher levels of air or surface viral contamination in the immediate care environment.

The noninvasive ventilation (NIV) course has been one of the most successful European Respiratory Society (ERS) courses for well over a decade, and more recently, the subject area has been divided into basic and advanced NIV courses to more comprehensively meet the needs of the multidisciplinary team. The advanced NIV course held in Milan in November 2018 aimed to provide participants, who already had some experience with NIV, with practical advice on acute and chronic NIV, an update on new techniques and on controversial and growing areas of practice., Participants attending the recent ERS course on advanced noninvasive ventilation share their experiences http://ow.ly/RiTH30odWuX

A commonly used approach to study the association between a time-varying biomarker, such as forced vital capacity (FVC), and a time-to-event outcome, such as new onset of chronic obstructive pulmonary disease (COPD), is to incorporate the biomarker as a time-dependent covariate in a Cox model. This approach, which is known as the time-dependent Cox model (TDCM), requires knowledge of the value of the time-varying biomarker at all time points at which the event of interest occurs [1]. However, in clinical studies, longitudinal biomarker measurements are taken intermittently during scheduled (and sometimes unscheduled) visits, meaning that imputation of missing values is required for those event times at which the biomarker is not observed. In practical application of the TDCM, this is achieved by carrying forward the most recent biomarker measurement. While the use of last observation carried forward (LOCF) is easy to understand and implement, the resulting step function (see fig. 1, panel C for an example) is unlikely to provide a good approximation of the true biomarker trajectory. Footnotes This manuscript has recently been accepted for publication in the European Respiratory Journal . It is published here in its accepted form prior to copyediting and typesetting by our production team. After these production processes are complete and the authors have approved the resulting proofs, the article will move to the latest issue of the ERJ online. Please open or download the PDF to view this article. Conflict of interest: Dr. Chen has nothing to disclose. Conflict of interest: Dr. Postmus has nothing to disclose. Conflict of interest: Dr. Cowie has nothing to disclose. Conflict of interest: Dr. Woehrle has nothing to disclose. Conflict of interest: Dr. Wegscheider has nothing to disclose. Conflict of interest: Dr. Simonds has nothing to disclose. Conflict of interest: Dr. Boezen has nothing to disclose. Conflict of interest: Dr. Somers reports other from Steering Committee SERV HF, outside the submitted work. Conflict of interest: Dr. Teschler has nothing to disclose. Conflict of interest: Dr. Eulenburg has nothing to disclose.

The clinical activities regarding sleep disordered breathing (SDB) have been sharply interrupted during the initial phase of the COVID-19 epidemic throughout Europe. In the last months, activities have gradually restarted, according to epidemiological phase of COVID-19 and National recommendations. The recent increase in cases throughout Europe obliges to reconsider management strategies of SDB accordingly. Diagnosis of SDB and initiation of treatment pose some specific problems to be addressed to preserve safety of the patients and health personnel. This perspective document by a group of European sleep experts aims at summarising some different approaches followed in Europe and United States, which reflect National recommendations according to the epidemiological phase of the COVID-19 infection. Respiratory sleep medicine will likely change in the near future, and use of telemedicine will grow to avoid unnecessary risks and continue to provide optimal care to the patients. The document also covers pediatric sleep studies and indications for titration of noninvasive ventilation, as well as precautions to be followed by patients who are already on positive airway pressure treatment. A single consensus document developed by the European Respiratory Society and National Societies would be desirable to harmonise SDB management throughout Europe., Specific precautions should be applied for starting activities in respiratory Sleep Centres during the COVID-19 epidemic

The coronavirus disease 2019 (COVID-19) pandemic has inflicted a considerable pressure on populations, healthcare systems and community organisations worldwide, due to the fast spread of the disease and its huge global burden of morbidity and mortality, healthcare resource consumption, and societal and economic implications [1]., Production of guidance in rapidly evolving areas where evidence is absent or fragile is challenging and needs to use rigorous methods interpreted with caution https://bit.ly/3jpChqk

Objective The trial objective is to determine if Continuous Positive Airway Pressure (CPAP) or High-Flow Nasal Oxygen (HFNO) is clinically effective compared to standard oxygen therapy in patients with confirmed or suspected COVID-19. Trial design Adaptive (group-sequential), parallel group, pragmatic, superiority randomised controlled, open-label, multi-centre, effectiveness trial. Participants The trial is being conducted across approximately 60 hospitals across England, Wales, Scotland, and Northern Ireland. Inpatients at participating hospitals are eligible to participate if they have respiratory failure with suspected or proven COVID-19, and meet all of the inclusion criteria and none of the exclusion criteria. Inclusion criteria: 1) Adults ≥ 18 years; 2) Admitted to hospital with suspected or proven COVID-19; 3) Receiving oxygen with fraction of inspired oxygen (FiO2) ≥0.4 and peripheral oxygen saturation (SpO2) ≤94%; and 4) Plan for escalation to tracheal intubation if needed. Exclusion criteria: 1) Planned tracheal intubation and mechanical ventilation imminent within 1 hour; 2) Known or clinically apparent pregnancy; 3) Any absolute contraindication to CPAP or HFNO; 4) Decision not to intubate due to ceiling of treatment or withdrawal of treatment anticipated; and 5) Equipment for both CPAP and HFNO not available. Intervention and comparator Intervention one: Continuous positive airway pressure delivered by any device. Set-up and therapy titration is not protocolised and is delivered in accordance with clinical discretion. Intervention two: High-flow nasal oxygen delivered by any device. Set-up and therapy titration is not protocolised and is delivered in accordance with clinical discretion. Comparator group: Standard care- oxygen delivered by face mask or nasal cannula (excluding the use of continuous positive airway pressure or high-flow nasal oxygen). Set-up and therapy titration is not protocolised and is delivered in accordance with clinical discretion. Intervention delivery continues up to the point of death, tracheal intubation, or clinical determination that there is no ongoing need (palliation or improvement). Main outcomes The primary outcome is a composite outcome comprising tracheal intubation or mortality within 30 days following randomisation. Secondary outcomes include tracheal intubation rate, time to tracheal intubation, duration of invasive ventilation, mortality rate, time to mortality, length of hospital stay, and length of critical care stay. Randomisation Participants are randomised in a 1:1:1 ratio to receive either continuous positive airway pressure, high-flow nasal oxygen or standard care. Due to the challenging environment of study delivery, a specific intervention may not always be available at the hospital site. The study uses two integrated randomisation systems to allow, where required, the site to randomise between all three interventions, between CPAP and standard care, and between HFNO and standard care. System integration ensures maintenance of balance between interventions. Randomisation is performed using a telephone-based interactive voice response system to maintain allocation concealment. The randomisation sequence was computer-generated using the minimisation method. Participant randomisation is stratified by site, gender (M/F), and age (=50 years). Blinding (masking) The nature of the trial interventions precludes blinding of the researcher, patient and clinical team. Primary and secondary outcomes are all objective outcomes, thereby minimising the risk of detection bias. Numbers to be randomised (sample size) 4002 participants (1334 to be randomized to each of the three study arms) Trial Status Current protocol: Version 4.0, 29th May 2020. Recruitment began on April 6, 2020 and is anticipated to be complete by April 5, 2021. The trial has been awarded Urgent Public Health status by the National Institute of Health Research on 13th April 2020. Trial registration ISRCTN, ISRCTN16912075. Registered 6th April 2020, http://www.isrctn.com/ISRCTN16912075 Full protocol The full protocol (version 4.0, 29th May 2020) is attached as an additional file, accessible from the Trials website (Additional file 1). In the interest in expediting dissemination of this material, the familiar formatting has been eliminated; this Letter serves as a summary of the key elements of the full protocol. The study protocol has been reported in accordance with the Standard Protocol Items: Recommendations for Clinical Interventional Trials (SPIRIT) guidelines (Additional file 2).

Sleep and breathing disorders are highly prevalent, representing a growing subspecialty of respiratory medicine. The term sleep disordered breathing (SDB) encompasses a range of conditions characterised by abnormal breathing during sleep, from chronic or habitual snoring, to frank obstructive sleep apnoea (OSA) or, in some cases, central sleep apnoea (CSA) and hypoventilation syndromes. OSA is the commonest form of SDB, leading to many potential consequences and adverse clinical outcomes, including excessive daytime sleepiness, impaired daytime function, metabolic dysfunction, and an increased risk of cardiovascular disease and mortality [1]. The estimated reported prevalence of moderate-to-severe SDB (≥15 events·h−1) was 23.4% in women and 49.7% in men, and the prevalence of symptomatic OSA was 9% and 13%, respectively [2]. However, in some populations, the prevalence of OSA is substantially higher, such as in patients been evaluated for bariatric surgery (estimated range 70–80%), in patients who have had a transient ischaemic attack or stroke (estimated range 60–70%) and in patients with cardiometabolic disease [3–6]. Limited data have been reported on CSA and non-obstructive sleep-related hypoventilation, which have received considerable interest in the sleep field within the past 10 years. Even if their prevalence was noted to be quite low relative to the prevalence of OSA [7], they are quite common in specific subpopulations [8–10]., The @EuroRespSoc launches a new sleep and breathing disorders continuous professional development programme http://bit.ly/30PU01P

Background Many people are dying from COVID-19, but consensus guidance on palliative care in COVID-19 is lacking. This new life-threatening disease has put healthcare systems under pressure, with increased need of palliative care provided to many patients by clinicians with limited prior experience in this field. Therefore, we aimed to make consensus recommendations for palliative care for patients with COVID-19 using the Convergence of Opinion on Recommendations and Evidence (CORE) process. Methods We invited 90 international experts to complete an online survey including stating their agreement, or not, with 14 potential recommendations. At least 70% agreement on directionality was needed to provide consensus recommendations. If consensus was not achieved on the first round, a second round was conducted. Results 68 experts (75.6%) responded in the first round. Most participants were experts in palliative care, respiratory medicine or critical care medicine. In the first round, consensus was achieved on 13 recommendations based upon indirect evidence and clinical experience. In the second round, 58/68 (85.3%) of the first round experts responded, resulting in consensus also for the 14th recommendation. Conclusions This multi-national task force provides consensus recommendations for palliative care for patients with COVID-19 concerning: advance care planning; (pharmacological) palliative treatment of breathlessness; clinician-patient communication; remote clinician-family communication; palliative care involvement in patients with serious COVID-19; spiritual care; psychosocial care; and bereavement care. Future studies are needed to generate empirical evidence for these recommendations., Multi-national task force provides consensus recommendations for palliative care for patients with COVID-19.

International audience; Aims: The Treatment of Sleep-Disordered Breathing with Predominant Central Sleep Apnoea by Adaptive Servo Ventilation in Patients with Heart Failure trial investigated the effects of adaptive servo-ventilation (ASV) (vs. control) on outcomes of 1325 patients with heart failure and reduced ejection fraction (HFrEF) and central sleep apnoea (CSA). The primary outcome (a composite of all-cause death or unplanned HF hospitalization) did not differ between the two groups. However, all-cause and cardiovascular (CV) mortality were higher in the ASV group. Circulating biomarkers may help in better ascertain patients’ risk, and this is the first study applying a large set of circulating biomarkers in patients with both HFrEF and CSA.Methods and results: Circulating protein-biomarkers (n = 276) ontologically involved in CV pathways, were studied in 749 (57% of the trial population) patients (biomarker substudy), to investigate their association with the study outcomes (primary outcome, CV death and all-cause death). The mean age was 69 ± 10 years, and > 90% were male. The groups (ASV vs. control and biomarker substudy vs. no biomarker) were well balanced. The “best” clinical prognostic model included male sex, systolic blood pressure < 120 mmHg, diabetes, loop diuretic, cardiac device, 6-min walking test distance, and N-terminal pro BNP as the strongest prognosticators. On top of the “best” clinical prognostic model, the biomarkers that significantly improved both the discrimination (c-index) and the net reclassification index (NRI) of the model were soluble suppression of tumorigenicity 2 for the primary outcome; neurogenic locus notch homolog protein 3 (Notch-3) for CV-death and all-cause death; and growth differentiation factor 15 (GDF-15) for all-cause death only.Conclusions: We studied 276 circulating biomarkers in patients with HFrEF and central sleep apnoea; of these biomarkers, three added significant prognostic information on top of the best clinical model: soluble suppression of tumorigenicity 2 (primary outcome), Notch-3 (CV and all-cause death), and GDF-15 (all-cause death).

Spinal muscular atrophy (SMA) is a severe neuromuscular disorder due to a defect in the survival motor neuron 1 (SMN1) gene. Its incidence is approximately 1 in 11,000 live births. In 2007, an International Conference on the Standard of Care for SMA published a consensus statement on SMA standard of care that has been widely used throughout the world. Here we report a two-part update of the topics covered in the previous recommendations. In part 1 we present the methods used to achieve these recommendations, and an update on diagnosis, rehabilitation, orthopedic and spinal management; and nutritional, swallowing and gastrointestinal management. Pulmonary management, acute care, other organ involvement, ethical issues, medications, and the impact of new treatments for SMA are discussed in part 2.

Pneumonia is a leading global cause of morbidity and mortality, particularly amongst adults aged >70 years and children. Annual deaths due to pneumonia in these groups was estimated at more than one million and 672 000 worldwide for both groups, respectively, in 2019 [1]. The importance of pneumonia is highlighted by impact of the current coronavirus disease 2019 (COVID-19) pandemic on vulnerable populations. Yet, despite the high impact of pneumonia worldwide, diagnosing pneumonia, especially in children in low- and middle-income countries, remains a big challenge. Frequent clinical signs of pneumonia (cough and difficult or rapid breathing) are non-specific and can overlap with other prevalent diseases in these settings, such as malaria. Equally important, data provided by the World Health Organization (WHO) revealed that 40% of children with pneumonia symptoms in the 40 countries reporting 90% of child pneumonia deaths never receive medical care for their pneumonia [2]. Furthermore, overdiagnosis of bacterial pneumonia and unnecessary administration of antibiotics poses an extra challenge, particularly in countries with limited resources for diagnostic procedures.

Aims The SERVE-HF trial investigated the impact of treating central sleep apnoea (CSA) with adaptive servo-ventilation (ASV) in patients with systolic heart failure. A preplanned substudy was conducted to provide insight into mechanistic changes underlying the observed effects of ASV, including assessment of changes in left ventricular function, ventricular remodelling, and cardiac, renal and inflammatory biomarkers. Methods and results In a subset of the 1325 randomised patients, echocardiography, cardiac magnetic resonance imaging (cMRI) and biomarker analysis were performed at baseline, and 3 and 12 months. In secondary analyses, data for patients with baseline and 12-month values were evaluated; 312 patients participated in the substudy. The primary endpoint, change in echocardiographically determined left ventricular ejection fraction from baseline to 12 months, did not differ significantly between the ASV and the control groups. There were also no significant between-group differences for changes in left ventricular dimensions, wall thickness, diastolic function or right ventricular dimensions and ejection fraction (echocardiography), and on cMRI (in small patient numbers). Plasma N-terminal pro B-type natriuretic peptide concentration decreased in both groups, and values were similar at 12 months. There were no significant between-group differences in changes in cardiac, renal and systemic inflammation biomarkers. Conclusion In patients with systolic heart failure and CSA, addition of ASV to guideline-based medical management had no statistically significant effect on cardiac structure and function, or on cardiac biomarkers, renal function and systemic inflammation over 12 months. The increased cardiovascular mortality reported in SERVE-HF may not be related to adverse remodelling or worsening heart failure.

Background and objective A good mask fit, avoiding air leaks and pressure effects on the skin are key elements for a successful noninvasive ventilation (NIV). However, delivering practical training for NIV is challenging, and it takes time to build experience and competency. This study investigated whether a pressure sensing system with real-time visual feedback improved mask fitting. Methods During an NIV training session, 30 healthcare professionals (14 trained in mask fitting and 16 untrained) performed two mask fittings on the same healthy volunteer in a randomized order: one using standard mask-fitting procedures and one with additional visual feedback on mask pressure on the nasal bridge. Participants were required to achieve a mask fit with low mask pressure and minimal air leak (

Introduction Paediatric obstructive sleep apnoea is associated with systemic inflammation and co-morbidities. We assessed whether sleep disordered breathing (SDB) due to neuromuscular weakness was associated with elevated airway and systemic pro-inflammatory cytokines. Methods Consecutive neuromuscular children (age 5–18years) underwent overnight full polysomnography and morning collection of serum and breath condensate, analysed for cytokines (Interleukin-10, Interleukin-6, Interleukin-1β, Tumour Necrosis Factorα, high-sensitivity C-Reactive Protein, Intercellular and Vascular Adhesion Molecules ICAM-1, VCAM-1). Cytokine levels were related to Oxygen desaturation index (ODI), desaturation>4%/h, and levels of transcutaneous carbon dioxide overnight (tcCO2≥6.7 kPa > 2% sleep). Results A total of 23 patients were included, median age 12.6 years (IQR 8.7–14.6). ODI>3/h was associated with higher breath and serum IL-6 (p = 0.02). Children with elevated CO2 overnight had higher ICAM-1 and VCAM-1. CO2 levels correlated with serum ICAM-1 (rs0.570, p = 0.026) and VCAM-1 (rs0.76, p = 0.001). Discussion SDB in neuromuscular children is associated with raised serum IL-6, VCAM-1, ICAM-1. This may predispose these children to future cardiovascular and other co-morbidities.

Mechanical insufflation-exsufflation (MI-E) devices increase expiratory air flow and thereby promote increased cough peak flow (CPF) in conjunction with a cough. There is little research looking at long-term use of MI-E in subjects with neuromuscular disease (NMD), and no long-term study has reported CPF, MI-E device settings, and adherence.We evaluated 181 patient records (130 adults, 51 children) of individuals who received a MI-E device from our center between February 2014 and February 2018. Median age (interquartile range [IQR]) was 27 (14-51) y. Duchenne muscular dystrophy (DMD), spinal muscular atrophy (SMA), and amyotrophic lateral sclerosis (ALS) were the 3 most common diagnoses.MI-E devices were provided to the weakest subjects with a CPF160 L/min. Median (IQR) settings were insufflation, 25 (23-30) cm HGreater exsufflation pressures than insufflation pressures, together with a shorter insufflation time than exsufflation time, were used. Predicting good adherence among the subjects was difficult. Subjects who produced daily secretions were more likely to use MI-E every day.

The European Respiratory Society (ERS) Presidential Summit is an annual event in the diary of the ERS President and the ERS leadership. It is an occasion where the ERS President can select a topic of relevance to the respiratory field, but one that has a more societal focus and one that transcends boundaries between diseases. The summit has the scope of raising awareness about lung health and disease, building alliances and helping promote better health. It allows the leadership of the ERS, as well as key stakeholders in health, to look at an issue from a wider perspective, to learn from other disciplines, and to discuss and debate., The ERS Presidential Summit is an annual event in the diary of the ERS President and leadership. The summit has the scope of raising awareness about lung health and disease, building alliances and helping better health. http://ow.ly/3Lt730lG31k

International audience; INTRODUCTION:The SERVE-HF trial included patients with heart failure and reduced ejection fraction (HFrEF) with sleep-disordered breathing, randomly assigned to treatment with Adaptive-Servo Ventilation (ASV) or control. The primary outcome was the first event of death from any cause, lifesaving cardiovascular intervention, or unplanned hospitalization for worsening heart failure. A subgroup analysis of the SERVE-HF trial suggested that patients with Cheyne-Stokes respiration (CSR) 90% were male. Patients with CSR

BACKGROUND: The evidence base for the treatment of mild obstructive sleep apnoea is limited and definitions of disease severity vary. The MERGE trial investigated the clinical effectiveness of continuous positive airway pressure in patients with mild obstructive sleep apnoea. METHODS: MERGE, a multicentre, parallel, randomised controlled trial enrolled patients (≥18 years to ≤80 years) with mild obstructive sleep apnoea (apnoea-hypopnoea index [AHI] ≥5 to ≤15 events per h using either AASM 2007 or AASM 2012 scoring criteria) from 11 UK sleep centres. Participants were assigned (1:1) to either 3 months of continuous positive airway pressure plus standard care (sleep counselling), or standard care alone, by computer-generated randomisation; neither participants nor researchers were blinded. The primary outcome was a change in the score on the Short Form-36 questionnaire vitality scale in the intention-to-treat population of patients with mild obstructive sleep apnoea diagnosed using the American Academy of Sleep Medicine 2012 scoring criteria. The study is registered with ClinicalTrials.gov, NCT02699463. FINDINGS: Between Nov 28, 2016 and Feb 12, 2019, 301 patients were recruited and randomised. 233 had mild obstructive sleep apnoea using AASM 2012 criteria and were included in the intention-to-treat analysis: 115 were allocated to receive continuous positive airway pressure and 118 to receive standard care. 209 (90%) of these participants completed the trial. The vitality score significantly increased with a treatment effect of a mean of 10·0 points (95% CI 7·2-12·8; p

Introduction: Recent data suggested that different ASV devices are associated with different outcomes based on a physiological experiment in complex sleep apnoea patients with preserved ejection fraction (n=14). Due to changes in technology over time, two different ASV devices were used in the SERVE-HF study of heart failure patients with reduced ejection fraction (Cowie et al. NEJM 2015;373:1095–105). Aim: To compare outcomes by ASV device used in SERVE-HF (n=1325). Methods: Outcome data from the SERVE-HF study were retrospectively analysed based on stratification by ASV device used (AutoSet CS2 at trial start [2009], moving to AutoSet S9SC from 2011; trial end 2013). CS2 was the only device used in 2009 and 2010, and S9SC was the only device used in 2013; in 2011 and 2012 the number of patients using CS2 and S9SC was 65 and 54, and 5 and 145, respectively. Control group patients who started ASV were also included in the analysis. Results: There was no effect of ASV device type on the primary endpoint (left figure), the rate of cardiovascular death (right figure), or on the rate of non-cardiovascular death. No significant interactions were found between device type and the primary endpoint (p=0.572), cardiovascular death (p=0.674) or non-cardiovascular death (p=0.071). Conclusion: Data from the large, randomised, SERVE-HF trial did not show any differential effects of ASV on outcome based on device type.

Prevalence studies have shown heterogeneous use of home mechanical ventilation in different conditions, with a marked increase in uptake especially in users of noninvasive ventilation. Although randomized controlled trials have examined noninvasive ventilation in acute exacerbations of chronic obstructive pulmonary disease, for weaning from invasive ventilation and for postextubation respiratory failure, the evidence base for long-term noninvasive ventilation and comparisons with invasive ventilation are less well developed. The combination of noninvasive ventilation and cough-assist devices has reduced the indications for tracheotomy ventilation in some situations (e.g., Duchenne muscular dystrophy, spinal muscular atrophy, myopathies, and amyotrophic lateral sclerosis) and has also prolonged survival. Several excellent overviews have been written on the history of home mechanical ventilation and its evolution from negative pressure to positive pressure techniques, including a systematic review of outcomes. This review, instead, will cover recent trials, trends in the field, outcomes, and safety. Because the greatest growth has been in home noninvasive ventilation, this will be the main focus of this article.

OBJECTIVE: To assess the impact of home telemonitoring on health service use and quality of life in patients with severe chronic lung disease. DESIGN: Randomised crossover trial with 6 months of standard best practice clinical care (control group) and 6 months with the addition of telemonitoring. PARTICIPANTS: 68 patients with chronic lung disease (38 with COPD; 30 with chronic respiratory failure due to other causes), who had a hospital admission for an exacerbation within 6 months of randomisation and either used long-term oxygen therapy or had an arterial oxygen saturation (SpO2) of

Despite the fact that metanalyses and clinical guidelines do not recommend the routine use of domiciliary non-invasive ventilation (NIV) for patients diagnosed with severe stable Chronic Obstructive Pulmonary Disease (COPD) and with chronic respiratory failure, it is common practice in some countries.We conducted an international web-survey of physicians involved in provision of long-term NIV to examine patterns of domiciliary NIV use in patients diagnosed with COPD.The response rate was 41.6%. A reduction of hospital admissions, improvements in quality of life and dyspnea relief were considered as the main expected benefits for patients. Nocturnal oxygen saturation assessment was the principal procedure performed before NIV prescription. Recurrent exacerbations (>3) requiring NIV and failed weaning from in hospital NIV were the most important reasons for starting domiciliary NIV. Pressure support ventilation (PSV) was the most common mode, with low intensity settings (PSV-low) the most popular (44.4 30.1%) compared with high intensity (PSV-high) strategies (26.9 +/- 25.9%), with different geographical preferences.COPD is confirmed to be a common indication for domiciliary NIV. Recurrent exacerbations and failed weaning from in-hospital NIV were the main reasons for its prescription.

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BACKGROUND AND OBJECTIVE Increases in Cheyne-Stokes respiration (CSR) cycle length (CL), lung-to-periphery circulation time (LPCT) and time to peak flow (TTPF) may reflect impaired cardiac function. This retrospective analysis used an automatic algorithm to evaluate baseline CSR-related features and then determined whether these could be used to identify patients with systolic heart failure (HF) who experienced serious adverse events in the Treatment of Sleep-Disordered Breathing with Predominant Central Sleep Apnea by Adaptive Servo Ventilation in Patients with Heart Failure (SERVE-HF) substudy. METHODS A total of 280 patients had overnight diagnostic polysomnography data available; an automated algorithm was applied to quantify CSR-related features. RESULTS Median baseline CL, LPCT and TTPF were similar in the control (n = 152) and adaptive servo-ventilation (ASV, n = 156) groups. In both groups, CSR-related features were significantly longer in patients who did (n = 129) versus did not (n = 140) experience a primary endpoint event (all-cause death, life-saving cardiovascular intervention or unplanned hospitalization for worsening HF): CL, 61.1 versus 55.1 s (P = 0.002); LPCT, 36.5 versus 31.5 s (P

Background: Patients with pulmonary hypertension (PH) in respiratory disease (group 3 PH) have adverse outcomes. Some studies suggest that patients with more severe PH (mPAP≥35mmHg) benefit from sildenafil use. Aims: To assess short term outcomes following sildenafil use in patients with severe group 3 PH. Methods: Patients from the Royal Brompton Hospital were assessed at baseline and 3-6 month follow-up using right heart catheterisation (RHC), echocardiography, brain natriuretic peptide (BNP), 6-minute walk test (6MW) and a PH-specific quality of life score (EmPHasis-10, E10). Other contributing factors to PH were excluded. Sildenafil was initiated at 12.5-25mg TDS. Data are mean±SD or median (IQR). Results: Patients (n=18) were 50% male, 63.5±11.3 years with ILD (n=8), combined pulmonary fibrosis and emphysema (n=3), COPD (n=4) and sleep disorders (n=3), had FEV1 64.3±30.9%, FVC 73.8±33.4%, FEV/FVC 71.7±16.9%, TLCO 22.4±6.4% and KCO 47.5±33.8% predicted. RHC showed mPAP 47.4±11.0mmHg, PCWP 9±4mmHg and PVR 10.7±5.1 Wood units. 3/18 did not tolerate sildenafil (hypotension, no benefit, unmasking of diastolic dysfunction). At 3-6 months, BNP fell from 699±646 to 451±450, p=0.02, E10 improved from 37±10 to 29±12, p=0.002. WHO functional class improved, p=0.054 (Figure A-D). Conclusion: Sildenafil was well tolerated in patients with severe group 3 PH, with improved WHO FC, BNP and quality of life, and a good safety signal. Larger studies are warranted.

Background: IPE “occurs when two or more professionals learn with, from and about each other to improve collaboration and quality of care.” (Barr H et al. Introducing interprofessional education; 2013). As patients’ needs become more complex, collaboration across professional and physical boundaries becomes more vital. Individuals with NMD including myotubular myopathy (MM) have complex cormorbidities, and positive outcomes require coordinated care from hospital to home. Objectives: We designed a one day training programme for respiratory care in MM, to explore whether IPE is feasible and improves confidence in clinical practice in this area. Methods: The training programme included didactic sessions, workshops and networking opportunities. Participants completed pre- and post-course Likert scale assessments of confidence in respiratory care in MM and gave qualitative feedback. Results: N=22: 5 relatives; 1 patient; 4 physicians; 7 nurses; 4 physiotherapists; 1 physiologist. Participants9 confidence in most domains improved significantly. Participants commented on the value of networking and information sharing. Conclusions: IPE offers a promising approach to training in respiratory care in NMD. Further work is required to determine whether IPE improves collaboration and clinical outcomes.

There is a well-established evidence base for prescribing long-term oxygen therapy in chronic obstructive pulmonary disease, and this has been extrapolated to management of hypoxaemia in other conditions such as interstitial lung disease and chronic pulmonary hypertension. Non-invasive ventilation reduces mortality in chronic stable hypercapnic patients with chronic obstructive pulmonary disease and those who remain persistently hypercapnic following an acute infective exacerbation. In patients with some neuromuscular disorders, non-invasive ventilation may increase survival and quality of life significantly. Few cardiovascular endpoints have been monitored systematically in these populations.

Introduction A typical patient, with hypertension, diabetes or obesity, presenting with breathlessness and fatigue may be referred for cardiovascular review, but likewise for sleep apnoea assessment. In the symptomatic patient, current guidelines indicate the use of natriuretic peptides and echocardiography for diagnostic work-up of heart failure. We aimed to determine the prevalence of heart failure with preserved ejection fraction (HFpEF) in patients referred for sleep apnoea testing. Methods Patients scheduled for a diagnostic respiratory polygraphy were recruited as part of an ongoing prospective, observational study. Exclusion criteria included age Results Preliminary data for 40 patients are presented in this abstract. Hypertension, obesity and diabetes were highly prevalent (Table 1). Sleep apnoea was identified in 27 patients (68%). 63% were breathless and 30% had peripheral oedema. All were in sinus rhythm. NT-proBNP levels ranged between 5–483 pg/ml. Nine patients (22.5%) had NT-proBNP levels above 125 pg/ml, the NICE recommended threshold for echocardiography referral. Of these, six patients (65%) had normal diastolic and systolic function. One patient had definite diastolic dysfunction by ASE and EACI 2016 criteria. One patient had severe septal left ventricular hypertrophy. No significant correlation between NT-proBNP and SDB severity (apnoea-hypopnoea index) was seen (r=−0.08, p=0.961). Conclusion Cardiovascular risk factors are highly prevalent in patients referred for sleep apnoea assessment. However, among this population HFpEF is uncommon. Given the considerable proportion of false positive NT-proBNP levels, biomarker screening for heart failure in these patients may have limited benefit. The value of echocardiography, however, remains to be determined. We wish to present our full study results at BCS 2018.

BACKGROUND: Mechanically assisted cough devices are used in patients with impaired cough to avoid secretion accumulation. We compared 5 mechanically assisted cough devices by bench testing using a breathing simulator and assessed their user-friendliness. METHODS: We measured inspiratory and expiratory airway pressures and peak expiratory flow, the strongest indicator of cough efficacy. We performed 2 bench tests: 1) to ascertain the differences between preset and actual settings in 3 different machines of each mechanically assisted cough device and 2) to assess the effects of varying respiratory impedance and air leaks on performance of the devices. We also evaluated the user-friendliness of the devices by measuring the time required and errors in accomplishing 4 tasks by 10 physicians unfamiliar with mechanically assisted cough devices compared with product specialists from the distributing companies. Physicians also scored the ease of use. RESULTS: Four mechanically assisted cough devices during insufflation and all 5 during exsufflation showed differences between preset and actual airway pressures. All but one device showed uneven actual pressure values between models of the same type. Peak expiratory flow was significantly influenced by the mechanical properties in 2 devices and by air leaks in 4 devices. The median time to accomplish all tasks by the product specialist (10 [interquartile range of 2–29] s) was overall significantly shorter compared with all physicians (from 19 [14–65] to 36 [19–116] s). The number of procedural errors, but not the perceived ease of use, differed significantly between the devices. CONCLUSIONS: The performance of different mechanically assisted cough devices was erratic and included variance between models from the same manufacturer; it was affected by respiratory system impedance and air leaks. Time and rate of errors for performing procedures were elevated. These findings indicate that the devices are not interchangeable and that the settings should be targeted for each patient with the specific machine being used. Improvements in reliability, performance, and user-friendliness are advisable. Key words: cough; physical therapy modalities; respiratory therapy; pulmonary medicine; mechanical ventilators; critical care. [Respir Care 2015;60(7):975–982. © 2015 Daedalus Enterprises]