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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.

Background and aim: Obstructive sleep apnea (OSA) is an independent risk factor for dyslipidemia. The current study examined the effects of positive airway pressure (PAP) treatment on lipid status in the European Sleep Apnea Database (ESADA). Methods: The prospective cohort study enrolled 1564 OSA subjects (74% male, mean age 54 ± 11y, body mass index (BMI) 32.7 ± 6.6 kg/m2 and apnea-hypopnea index (AHI) 40.3 ± 24.4 n/h) undergoing PAP therapy for at least three months (mean 377.6 ± 419.5 days). Baseline and follow-up total cholesterol (TC) from nine centers were analyzed. Repeated measures and logistic regression tests (adjusted for age, sex, weight changes, lipid lowering medication, PAP compliance, and treatment duration) were used to compare changes in TC concentration. Incident risk for a coronary heart disease event (CHD) was used to compute a Framingham CHD risk score (estimated from age, BMI, blood pressure, and TC). Results: Adjusted means of TC decreased from 194.2 mg/dl to 189.3 mg/dl during follow-up (p = 0.019). A clinically significant (10%) reduction of TC at PAP follow-up was observed in 422 patients (27%). Duration of PAP therapy was identified as independent predictor for TC reduction, which implies an approximately 10% risk reduction for incident CHD events (from 26.7% to 24.1% in men and from 11.2% to 10.1% in women, p < 0.001 respectively). Conclusion: This observational study demonstrates a reduction of TC after long-term PAP treatment. The close association between TC concentration and cardiovascular (CV) mortality suggests that identification and treatment of OSA may have a beneficial effect on overall CV risk due to this mechanism. This possibility needs to be evaluated in prospective randomized studies. © 2020 Elsevier B.V., ResMed Foundation European Respiratory Society, ERS European Respiratory Society, ERS European Respiratory Society, ERS, The ESADA network has received support from the European Union COST action B26 and the European Respiratory Society (ERS) funded Clinical Research Collaboration (CRC). Unrestricted seeding grants from the ResMed Foundation and the Philips Respironics Foundation for establishment of the database in 2007 and 2011 are gratefully acknowledged. The ESADA network has a scientific collaboration with Bayer AG., Nonfinancial support was provided by the European Sleep Research Society (ESRS) and the European Respiratory Society (ERS) in terms of logistics for communication, meetings and data presentations for the ESADA collaborators., Dr. Verbraecken reports grants and personal fees from ResMed, Bioprojet, Jazz Pharmaceutics; personal fees from Philips, Sanofi, Agfa-Gevaert, grants from AirLiquide; personal fees from Springer, Westfalen Medical, SomnoMed, Vivisol, Total Care, Medidis, Fisher & Paykel, Wave Medical, OSG, Mediq Tefa, NightBalance, Heinen & Löwenstein, AstraZen, Accuramed, Bekaert Deslee Academy and UCB Pharma, outside the submitted work. Dr. Hedner reports grants from ResMed, Philips Respironics, and the European Respiratory Society all related to maintenance of database on behalf of the ESADA group during the conduct of the study. Dr. Grote reports grants from Bayer, Resmed, Respironics/Philips, and from the European Respiratory Society during the conduct of the study; non-financial support and other from Itamar Medical, Resmed, Philips, and Astra Zeneca, outside the submitted work. In addition, Dr. Grote has a patent on sleep apnea therapy licensed. The remaining co-authors have no conflict of interest to declare.

STUDY OBJECTIVES: The association of mild obstructive sleep apnea (OSA) with important clinical outcomes remains unclear. We aimed to investigate the association between mild OSA and systemic arterial hypertension (SAH) in the European Sleep Apnea Database cohort. METHODS: In a multicenter sample of 4,732 participants, we analyzed the risk of mild OSA (subclassified into 2 groups: mild(AHI 5

We thank doctors Park and Kang for their editorial that well summarized our article. Our common belief is that one of the possible consequences of untreated obstructive sleep apnea (OSA) is an accelerated deterioration of kidney function, and that more knowledge would be necessary on the possible protective effects of OSA treatments. To our knowledge, so far the only OSA therapy whose effects on renal function have been tested is continuous positive airway pressure (CPAP), and most , although not all studies, have demonstrated its benefits. Our own study, while confirming benefits of fixed CPAP, has demonstrated little effect of auto-adjusting CPAP (APAP). This finding may be of relevance as, at present, OSA treatment by APAP is largely used. Then, should we ban APAP as a therapeutic modality for patients with renal problems? Most studies comparing fixed CPAP and APAP have focused on correction of respiratory events during sleep, relief of sleepiness, tolerability and patients’ compliance in subjects with typical pure OSA. In fact, APAP devices have been designed as treatment tools for this subgroup of patients, and not for patients with comorbid OSA with other types of respiratory disorders. Accordingly, current guidelines do not recommend APAP therapy for OSA patients with comorbidities like chronic obstructive pulmonary disease (COPD) or congestive heart failure although, more recently, small studies have been published suggesting effectiveness of APAP in patients with both OSA and COPD (overlap syndrome). Other diseases are not specifically mentioned in guidelines as contraindications to APAP. However, efficacy of OSA treatment should not be evaluated just in terms of polysomnographic parameters or symptoms, but also for its ability to prevent or counteract OSA deleterious effects on various organs and functions. In that respect, many studies have been published about effects of CPAP treatment, but few of them compared effects of fixed CPAP and APAP. We are aware of some studies comparing effects of these treatment modalities on blood pressure, autonomic activity or insulin resistance. Most of them showed superiority of fixed CPAP but, altogether, they are few, and more data would be required. Inflammatory activation and enhanced renin aldosterone angiotensin system activity in OSA may contribute to accelerate the age-related decline in estimated glomerular filtration rate (eGFR). Several, although not all, studies suggested beneficial effects of CPAP treatment on those factors, but to our knowledge possible differential effects of fixed CPAP and APAP have not been investigated, and could account for a different evolution of renal function in patients treated by each CPAP modality. Investigations should be extended to effects of APAP devices working with different algorithms. Besides, effects of setting different pressure ranges on the APAP machines, implying different degrees of variability of the administered pressure, should be tested. Although changes in eGFR over time differed significantly between our patients treated by fixed CPAP and APAP, standard deviations of changes were large in both groups. This finding suggests that the rate of eGFR decline may show high interindividual variability in treated OSA patients. What could make an OSA patient more susceptible to renal injury is not entirely clear. One longitudinal study showed that spending ≥12% of sleep time with an oxygen saturation

The effect of positive airway pressure treatment on weight and markers of central obesity in patients with obstructive sleep apnea remains unclear. We studied the change in body weight and anthropometric measures following positive airway pressure treatment in a large clinical cohort. Patients with obstructive sleep apnea with positive airway pressure treatment from the European Sleep Apnea Database registry (n = 1, 415, 77% male, age 54 ± 11 [mean ± SD] years, body mass index 31.7 ± 6.4 kg/m2, apnea–hypopnea index 37 ± 24 n per hr, Epworth Sleepiness Scale 10.2 ± 5.0) were selected. Changes in body mass index and neck/waist/hip circumferences at baseline and at follow-up visit were analysed. Overall, body mass index (0.0 [95% confidence interval, −0.1 to 0.2] kg/m2) and neck circumference (0.0 (95% confidence interval, −0.1 to 0.1] cm) were unchanged after positive airway pressure treatment compared with baseline (follow-up duration 1.1 ± 1.0 years and compliance 5.2 ± 2.1 hr per day). However, in non- obese (body mass index

Funding Acknowledgements Type of funding sources: Public Institution(s). Main funding source(s): This study is part of Limburg Clinical Research Center, supported by the foundation Limburg Sterk Merk, province of Limburg, Flemish government, Hasselt University, Ziekenhuis Oost-Limburg and Jessa Hospital. Background Obstructive sleep apnea (OSA) is an important modifiable risk factor in patients with atrial fibrillation (AF). Unfortunately, it is underdiagnosed in daily clinical practice, although up to 62% of AF patients may have OSA. Early detection of OSA is essential for rhythm control in AF patients. Currently, the gold standard for diagnosing OSA is polysomnography (PSG), but besides being an expensive method, it also requires a supervised hospitalization of one night. There is a lack of accurate and easy-to-use tools to test for OSA that can be implemented in daily ambulatory care. Purpose This study examined the accuracy and user-friendliness of several (cardiorespiratory) polygraphy devices (PG) as a simple screening tool for OSA in an outpatient AF population. Methods This prospective cohort study determines the accuracy of 4 PGs [ApneaLink Air (ALA), SOMNOtouch RESP (STR), SpiderSAS (SpS), and Noxturnal T3 (Nox-T3)] in AF patients who underwent a PSG evaluation at two Belgian sleep clinics. All the patients were instructed and asked to use a PG for one night at home. The Apnea-Hypopnea Index (AHI) was used to identify if moderate to severe OSA was present, i.e. AHI ≥15. Moreover, specific AHI cut-off values for each PG were derived based on the receiver operating characteristics (ROC) curves (best Youden's J Index and an accuracy of more than 0.7 compared to PSG). In addition, patients completed a Comfort Questionnaire (CQ) in order to assess the PG’s user-friendliness. Results In total, 130 AF patients undergoing a PSG were included (100 who tested the three devices ALA, STR, SpS and 30 patients who only tested Nox-T3). Only the successful measurements (i.e. ≥4 hours of data on automated analysis; n=250, 75.8%) were examined. The success rate for the ALA, STR, SpS, and NOX-T3 devices was 72.0%, 73.0%, 79.0% and 86.7%, respectively. The optimal AHI cut-off value for each PG in screening for clinically relevant OSA (i.e. AHI ≥15 on PSG) was 7.0, 10.0, 19.5, and 11.1 for the ALA, STR, SpS, and Nox-T3, respectively. The Nox-T3 PG had the highest sensitivity (92.9%), specificity (75.0%) and accuracy (0.85) in comparison to the other three PGs (Table 1). In addition, the scores of three important questions of the CQ were higher for the patients with Nox-T3 compared to the other PGs (Table 2). Conclusion Our results demonstrate the usability of PGs as early OSA screening tools in AF patients. The Nox-T3 with an optimized AHI cut-off value of 11.1 seems to be the best option for ambulatory OSA screening, based both on accuracy and user-friendliness.

Study Objectives: Patients with chronic kidney disease (CKD) often report poor sleep quality, but they commonly exhibit OSA. The aim of this study was to evaluate the influence of OSA severity and of estimated glomerular filtration rate impairment on objective sleep quality in nondialyzed patients with CKD, defined as an estimated glomerular filtration rate, ResMed Foundation ResMed Foundation European Respiratory Society, ERS European Cooperation in Science and Technology, COST, All authors have seen and approved the manuscript. By submitting the manuscript to the journal, the authors affirm that it is an original manuscript, is unpublished work if not as an abstract, and is not under consideration elsewhere. Work for this study was performed at institutions listed in the acknowledgments. This study was funded by support for the European Sleep Apnea Database network from the European Union COST Action B26 and the European Respiratory Society–funded Clinical Research Collaboration (funding 2015–2020). Unrestricted seed grants from the ResMed Foundation and the Philips Respironics Foundation for the establishment of the database in 2007 and 2011 are gratefully acknowledged. The European Sleep Apnea Database has a scientific collaboration with Bayer AG. O.M., F.C, G.R., P.S., P.J., O.K.B., I.B., S.S., A.P., R.S., and J.V. do not have any financial interests or connections, direct or indirect, or other situations that might raise the question of bias in the work reported or the conclusions, implications, or opinions stated. J.H. reports grants from ResMed, Philips Respironics, Bayer, and the European Respiratory Society related to maintenance of the database on behalf of the European Sleep Apnea Database group. L.G. reports a collaboration between the European Sleep Apnea Database network and Bayer. M.R.B. reports research financial support by Vivisol and Medicair Italy and honoraria from ResMed and Bioproject.

Recent studies indicate that ambient temperature may modulate obstructive sleep apnoea (OSA) severity. However, study results are contradictory warranting more investigation in this field. We analysed 19,293 patients of the European Sleep Apnoea Database (ESADA) cohort with restriction to the three predominant climate zones according to the Koppen-Geiger climate classification: Cfb (warm temperature, fully humid, warm summer), Csa (warm temperature, summer dry, hot summer), and Dfb (snow, fully humid, warm summer). Average outside temperature values were obtained and several hierarchical regression analyses were performed to investigate the impact of temperature on the apnea-hypopnea index (AHI), oxygen desaturation index (ODI), time of oxygen saturation, Fundacao para a Ciencia e a Tecnologia (FCT), Portugal; European Union; ResMed Foundation; Philips Respironics Foundation; European Respiratory Society (ERS), RS received financial support by the Fundacao para a Ciencia e a Tecnologia (FCT), Portugal. We would like to thank the members of the Pneumology Department of the University Hospital Lisbon, in particular to Andreia Colaco (RN), Claudia Pereira (RN), Dina Fernandes (RN), and Cristina Barbara (MD, Professor) for their support. The ESADA network was founded during the COST action B26 supported by the European Union and is one of the Clinical Research Collaborations (CRC) funded by the European Respiratory Society (ERS). Unrestricted seeding grants from the ResMed Foundation and the Philips Respironics Foundation for establishment of the database in 2007 and 2011 are gratefully acknowledged. Non--financial support was provided by the European Sleep Research Society (ESRS) and the European Respiratory Society (ERS) in terms of logistics for communication, meetings, and data presentations for the ESADA collaborators.

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

Excessive daytime sleepiness (EDS) is a symptom of obstructive sleep apnea (OSA) that resolves under treatment with continuous positive airway pressure (CPAP). In some patients, sleepiness persists despite CPAP treatment. We retrospectively analyzed data on subjective residual EDS, assessed as an Epworth Sleepiness Scale score (ESS) >10, in patients from the European Sleep Apnea Database (n = 4,853, mean age +/- SD 54.8 +/- 11.8 years, 26.1% females), at baseline and at the first visit (median follow-up: 5 months, interquartile range 3-13). An ESS > 10 occurred in 56% of patients at baseline and in 28.2% of patients at follow-up. Residual EDS was analyzed in 2,190 patients (age: 55.1 +/- 12.0 years, 26.1% females) with sleep monitoring data (median follow-up: 3 months, interquartile range 1-15). Sleep studies during CPAP use were obtained in 58% of these patients; EDS was reported by 47.2% of patients at baseline and by 30.3% at follow-up. Residual OSA, defined as an apnea-hypopnea index >10/h, and insufficient CPAP adherence, defined as nightly use 10 at the first follow-up visit was associated directly with ESS at baseline and inversely with duration of follow-up, and CPAP use (R-2 of themodel: 0.417). EDS showed heterogeneity in different European countries both at baseline and at the first follow-up visit, suggesting modulation by cultural and lifestyle factors. In conclusion, residual EDS in CPAP-treated OSA occurred in approximately one in four patients at follow-up; its prevalence was highest (40%) in the first 3 months of treatment and subsequently decreased. The finding of residual EDS in a significant percentage of optimally treated OSA patients suggests that wake-promoting agents may be useful, but their indication should be evaluated after at least 3 months of treatment., European Respiratory Society; ResMed; Philips; Bayer Pharmaceuticals; MIAI @ Grenoble Alpes [ANR19P3IA0003], The ESADA study is a Clinical Research Collaboration funded by the European Respiratory Society and by grants from ResMed, Philips and Bayer Pharmaceuticals. JP and SB are partly supported by MIAI @ Grenoble Alpes (ANR19P3IA0003) . The funders were not involved in the study design, collection, analysis, interpretation of data, the writing of this article or the decision to submit it for publication.

International audience; Excessive daytime sleepiness (EDS) is a major symptom of obstructive sleep apnoea (OSA), defined as the inability to stay awake during the day. Its clinical descriptors remain elusive, and the pathogenesis is complex, with disorders such as insufficient sleep and depression commonly associated. Subjective EDS can be evaluated using the Epworth Sleepiness Scale, in which the patient reports the probability of dozing in certain situations; however, its reliability has been challenged. Objective tests such as the multiple sleep latency test or the maintenance of wakefulness test are not commonly used in patients with OSA, since they require nocturnal polysomnography, daytime testing and are expensive. Drugs for EDS are available in the United States but were discontinued in Europe some time ago. For European respiratory physicians, treatment of EDS with medication is new and they may lack experience in pharmacological treatment of EDS, while novel wake-promoting drugs have been recently developed and approved for clinical use in OSA patients in the USA and Europe. This review will discuss 1) the potential prognostic significance of EDS in OSA patients at diagnosis, 2) the prevalence and predictors of residual EDS in treated OSA patients, and 3) the evolution of therapy for EDS specifically for Europe.

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Objective/Background: The Clinical Global Impression scale (CGI) reflects the clinician's assessment of the disease impact on patient's global functioning. We assessed predictors of CGI scale rating in patients with obstructive sleep apnea (OSA). Patients/Methods: Consecutive patients with suspected OSA (n = 7581) were identified in the European Sleep Apnea Database (ESADA). Anthropometrics, comorbidities, apnea severity obtained by polygraphy or polysomnography, and daytime sleepiness [Epworth Sleepiness Scale (ESS)] were assessed. The CGI 7-point scale was completed at the end of the diagnostic process (CGI-severity, ie, CGI-S) and, in a sub-population, at treatment follow-up (CGI-Improvement). Results: CGI-S was rated mild to moderate in 44% of patients. CGI rating at any given apnea intensity was worse in women than in men (p < 0.01). Patients undergoing polygraphy (n = 5075) were more frequently rated as severely ill compared to those studied with polysomnography (19.0% vs 13.0%, p < 0.001). In patients aged

BACKGROUND: The impact of treating OSA on renal function decline is controversial. Previous studies usually included small samples and did not consider specific effects of different CPAP modalities. The aim of this study was to evaluate the respective influence of fixed and autoadjusting CPAP modes on estimated glomerular filtration rate (eGFR) in a large sample of patients derived from the prospective European Sleep Apnea Database cohort. METHODS: In patients of the European Sleep Apnea Database, eGFR prior to and after follow-up was calculated by using the Chronic Kidney Disease-Epidemiology Collaboration equation. Three study groups were investigated: untreated patients (n = 144), patients receiving fixed CPAP (fCPAP) (n = 1,178), and patients on autoadjusting CPAP (APAP) (n = 485). RESULTS: In the whole sample, eGFR decreased over time. The rate of eGFR decline was significantly higher in the subgroup with eGFR above median (91.42 mL/min/1.73 m(2)) at baseline (P < .0001 for effect of baseline eGFR). This decline was attenuated or absent (P < .0001 for effect of treatment) in the subgroup of patients with OSA treated by using fCPAP. A follow-up duration exceeding the median (541 days) was associated with eGFR decline in the untreated and APAP groups but not in the fCPAP group (P < .0001 by two-way ANOVA for interaction between treatment and follow-up length). In multiple regression analysis, eGFR decline was accentuated by advanced age, female sex, cardiac failure, higher baseline eGFR, and longer follow-up duration, whereas there was a protective effect of fCPAP. CONCLUSIONS: fCPAP but not APAP may prevent eGFR decline in OSA.

The background and purpose of the HERMES (Harmonising Education in Respiratory Medicine for European Specialists) initiative has been discussed at length in previous articles [1–3]. This article aims to provide more detailed and specific insight into the process and methodology of the Sleep HERMES Task Force in developing a core curriculum in respiratory sleep medicine.

Obstructive sleep apnoea (OSA) is associated with increased risk of dysglycaemia but the intimate link of these conditions with obesity makes discerning an independent relationship between them challenging. Glycosylated haemoglobin (HbA1c) levels predict adverse cardiovascular outcomes in nondiabetics but there is a lack of population-level data exploring the relationship of HbA1c with OSA. A cross-sectional analysis of 5294 participants in the multinational European Sleep Apnoea Cohort (European Sleep Apnoea Database) study was performed, assessing the relationship of OSA severity with HbA1c levels in nondiabetic subjects, with adjustment for confounding factors. HbA1c levels correlated significantly with OSA severity in univariate analysis. Following adjustment for confounding factors, apnoea-hypopnoea index (AHI) (standardised beta 0.158; p= 6.0% than those in the first quartile. In stratified analyses, OSA severity predicted glycaemic health irrespective of sleep study modality, sex, obesity or daytime sleepiness. OSA severity independently predicts glycaemic health in nondiabetic subjects. Further studies should assess the impact of OSA treatment on glycaemic health and elucidate underlying mechanisms.

The clinical characterisation and description of the obstructive sleep apnoea–hypopnoea syndrome (OSAHS) and related syndromes were mainly revealed by several epidemiological studies conducted over the past fifty years. These highly prevalent syndromes affect about 9% of middle-aged men and 4% of women. These syndromes have serious medical and social consequences, such as cardiovascular or metabolic diseases, and even premature death. Consequently, respiratory sleep medicine (RSM) evolved and has progressed rapidly within the sleep medicine field over recent decades. New diagnostic and therapeutic techniques have appeared in response to an increasing number of patients and clinical interventions. The research progressed to focus not only on the clinical and pathophysiological but also the genetic and molecular aspects of these syndromes [1–6]. Nevertheless, the literature in the field does not provide any clear consensus on diagnostic classification and assessment. No harmonised standards of training exist across Europe for respiratory sleep medicine. The European Respiratory Society (ERS) provided external and postgraduate courses but the requirements and expectations in the field were not being fulfilled. There was a need for a project supporting both the teaching and certification. For this reason, ERS supported an application for a Sleep Harmonised Education in Respiratory Medicine for European Specialists (HERMES) Task Force project which aimed at establishing common standards in respiratory sleep training and education, in an adaptable framework which can be extended across Europe. HERMES was a project established in 2005 to provide documentation for the training and certification of adult respiratory specialists. Since 2005, the HERMES framework has been adapted for projects including paediatric respiratory medicine, critical care medicine and the development of the European Spirometry Driving Licence (spirometry). Within the HERMES model, a process of establishing consensus standards for training largely follows four key phases (fig. 1). In line with this …

The clinical characterisation and description of the obstructive sleep apnoea/hypopnoea syndrome (OSAHS) and related syndromes have been revealed by several epidemiological studies conducted in the late 20th and 21st centuries. These highly prevalent syndromes affect about 9% of middle-aged males and 4% of females. These syndromes have serious medical and social consequences, such as cardiovascular or metabolic diseases and even premature death. Consequently, respiratory sleep medicine has evolved and progressed rapidly within the sleep medicine field over the last decades. New diagnostic and therapeutic techniques appeared in response to an increasing number of patients and clinical interventions. The research progressed to focus not only on the clinical and pathophysiological, but also on the genetic and molecular aspects of these syndromes [1–4]. Nevertheless, the literature in the field does not provide any clear consensus on diagnostic classification and assessment. No harmonised standards of training exist across Europe for respiratory sleep medicine. The European Respiratory Society (ERS) conducted a survey in 2010 to enquire about the structure and organisation of training in different countries within Europe. National experts in the field of respiratory sleep medicine from 21 different countries were consulted. They were first asked about the duration of training in respiratory disorders during sleep. A huge diversity in training organisations and durations was revealed. Across 18 collected responses, it was observed that nine countries do not have any specific training for the specialty. Those countries are Luxembourg, Belgium, Denmark, Greece, Sweden, Poland, Cyprus, Ireland and the UK. On the contrary, training is organised in the Czech Republic, Germany, Romania, Spain, Lithuania, Finland, Austria, the Slovak Republic and Lithuania but could last from 1 week to 12 yrs. Moreover, except for the UK and the …