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Obstructive sleep apnea (OSA) is a highly prevalent disease, and is traditionally associated with increased cardiovascular risk. The role of comorbidities in OSA patients has emerged recently, and new conditions significantly associated with OSA are increasingly reported. A high comorbidity burden worsens prognosis, but some data suggest that CPAP might be protective especially in patients with comorbidities. Aim of this narrative review is to provide an update on recent studies, with special attention to cardiovascular and cerebrovascular comorbidities, the metabolic syndrome and type 2 diabetes, asthma, COPD and cancer. Better phenotypic characterization of OSA patients, including comorbidities, will help to provide better individualized care. The unsatisfactory adherence to CPAP in patients without daytime sleepiness should prompt clinicians to examine the overall risk profile of each patient in order to identify subjects at high risk for worse prognosis and provide the optimal treatment not only for OSA, but also for comorbidities.

CPAP is the first-choice treatment for obstructive SDB, but the criteria to prescribe AutoBI are undefined. Trials of AutoBI ventilation in patients under titration for obstructive SDB from January 2015 to January 2017 ((n=67 out of 265 titrations) were reviewed to assess: a) their clinical features, b) the reason to shift from CPAP to AutoBI, and c) long-term compliance to treatment. AutoBI was used in cases of intolerance to high therapeutic CPAP levels (n=23) or incomplete resolution of SDB on CPAP (n=45). AutoBI failed in 11 patients (16.4%): 2 OSA patients (7.7%), 4 overlap patients (21%), and 5 OHS patients (22.7%). The Table reports the differences at diagnosis between patients prescribed CPAP or AutoBI (unpaired t-test, significance p

CPAP is the first-choice treatment for obstructive sleep-disordered breathing (O-SDB), while the criteria to prescribe AutoBI are undefined. Trials of AutoBI ventilation in patients (pts) treated for O-SDB from January 2015 to October 2016 (64 out of 242 titrations) were reviewed to assess: a) the clinical characteristics of these pts, b) the reason to shift from CPAP to AutoBI, c) the compliance to prescribed treatment. AutoBI was used in cases of intolerance to high therapeutic CPAP levels (n=21) or incomplete resolution of SDB on CPAP (n=43). The Table reports the differences between CPAP or AutoBI pts CPAP SDB diagnosis was: 82% OSA, 18% OSA-COPD Overlap in the CPAP group; 39% OSA, 28% OSA-COPD Overlap and 33% OHS in the AutoBI group (p In conclusion, AutoBi can be considered an effective and well-tolerated treatment in pts with obstructive SDB, especially in cases with severe obesity, nocturnal hypoventilation, or needing high therapeutic pressures.

Automatic bilevel ventilation (AutoBI) has been recently introduced to treat obstructive sleep-disordered breathing (SDB), but clinical experience is still limited. We revised the charts of patients treated for obstructive SDB in our sleep clinic in 2015 (n=214) to assess the frequency of trials of AutoBI ventilators (ResMed Auto25 or Respironics BiFlex), the clinical characteristics of these patients, the reason to shift from CPAP to AutoBI, and the outcome of AutoBI titration. A trial of domiciliary AutoBI was made in 44 patients (20.5%) intolerant to CPAP due to high CPAP levels (n=11) or who showed incomplete resolution of SDB on CPAP (n=33). The table reports the clinical data according to diagnosis. AutoBi was successful (i.e. resolution of SDB and improved CT90%/daytime arterial blood gases) in 34 patients (77%), and failed in 10 patients (4 OHS, 3 OSA and 3 overlap). Patients successfully treated were significantly less obese (BMI 37.9±6.8 kg/m 2 ) than patients showing failure of AutoBi (n=10, BMI 50.2±20.1 kg/m 2 , p=0.0035). Failure of AutoBi was mostly seen among patients with incomplete resolution of SDB, only one overlap patient being intolerant to high CPAP pressure. Our results suggest that AutoBi is an effective alternative treatment in patients with obstructive SDB, especially in patients intolerant to high CPAP and without extreme obesity or COPD.

Sleep disordered breathing (SDB) is often overlooked in hospitalized patients. We screened consecutive patients with cardiovascular (CV) comorbidities hospitalized for respiratory problems to study SDB prevalence and type. Patients did not refer typical clinical signs of SDB. Patients (n=34, 21 M, mean age±SD 71±12 yr, BMI: 31.9±5.8 kg/m2) were studied by polygraphy (SomnoLab, Weinmann, Germany) 4.5±3.2 days after admission for COPD exacerbation (COPD-E, n=20), pleural effusion (n=2), asthma exacerbation (n=2) or other causes (n=10). On admission, 18 patients showed respiratory failure (RF, hypoxemic: n=9, hypercapnic: n=9). CV comorbidities (1.7±0.8/patient) were: hypertension (n= 27), heart failure (n=3), arrhythmias (n=11), coronary artery (n=15) or cerebrovascular (n=3) disease. Results showed: AHI≤5 (n=5, 14.7%), AHI≤15+nocturnal hypoxemia (n=3, 8.8%), obstructive (n=16, 47.1%), and central/complex SDB (n=10, 29.4%). Mean AHI was higher in the latter group (28.0±14.5/h) compared to patients with obstructive SDB (15.0±14.0/h), nocturnal hypoxemia (6.3±2.4/h) or AHI≤5 (3.1±1.0/h, p=0.005 by ANOVA). SDB type and severity were similar in men and women, and distribution of SDB type was unaffected by COPD-E or RF. The number of CV comorbidities tended to be highest in patients with central/complex SDB, and lowest in those with nocturnal hypoxemia (p=0.08 by ANOVA, NS). Therefore, 76% of patients with CV comorbidities hospitalized for respiratory problems showed obstructive or central/complex SDB. Central SDB were more severe but less frequent than obstructive SDB, and female gender did not protect against SDB in this population. Funded by ERS STRTF 5329-2013.