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Continuous positive airway pressure (CPAP) reduces blood pressure levels in hypertensive patients with obstructive sleep apnoea (OSA). However, the role of CPAP in blood pressure and the metabolic profile in women has not yet been assessed. In this study we investigated the effect of CPAP on blood pressure levels and the glucose and lipid profile in women with moderate-to-severe OSA. A multicentre, open-label, randomised controlled trial was conducted in 307 women diagnosed with moderate-to-severe OSA (apnoea–hypopnoea index ≥15 events·h–1) in 19 Spanish Sleep Units. Women were randomised to CPAP (n=151) or conservative treatment (n=156) for 12 weeks. Changes in office blood pressure measures as well as in the glucose and lipid profile were assessed in both groups. Compared with the control group, the CPAP group achieved a significantly greater decrease in diastolic blood pressure (−2.04 mmHg, 95% CI −4.02– −0.05; p=0.045), and a nonsignificantly greater decrease in systolic blood pressure (−1.54 mmHg, 95% CI −4.58–1.51; p=0.32) and mean blood pressure (−1.90 mmHg, 95% CI −4.0–0.31; p=0.084). CPAP therapy did not change any of the metabolic variables assessed. In women with moderate-to-severe OSA, 12 weeks of CPAP therapy improved blood pressure, especially diastolic blood pressure, but did not change the metabolic profile, compared with conservative treatment., CPAP reduces blood pressure levels, but does not change the metabolic profile in women with sleep apnoea http://ow.ly/sW9h30bgbAy

Obstructive sleep apnea (OSA) is defined as episodes of upper airway obstructions during sleep. The method of choice in conservative treatment of OSA is the use of devices that produce positive airway pressure (CPAP). In patients with mild-moderate form of OSA, intraoral mandibular advancement devices (MAD) are applied. The aim of the study was to evaluate the therapeutic efficacy of MAD in patients with severe OSA who were unable to use CPAP. In this preliminary study three patients from a group of 25 severe OSA sufferers who failed to use CPAP, were included. The three patients underwent a triple polysomnographic (PSG) investigation: on CPAP, before MAD treatment, and during MAD. The patients completed the Epworth Sleepiness Scale questionnaire twice. We found significant improvements of subjective symptoms and PSG-evaluated variables after application of MAD in all three patients in comparison with both baseline and CPAP-recorded data. We conclude that MAD can be an alternative treatment option for severe OSA patients who are non-compliant with CPAP therapy.

Continuous positive airway pressure (CPAP), the gold standard for the treatment of patients with obstructive sleep apnea (OSA) syndrome, was introduced by Sullivan in 1981. CPAP acts as an air splinter to support the collapsing upper airway during sleep. The mask, the interface between CPAP and the patient, plays a major role in patient acceptance and compliance with treatment. Improvements in mask materials, design, and aerodynamics have over time continued to increase patient compliance in the use of CPAP. Optimized pressure titration and mask fitting, as well as educational programs, are key factors that have increased the likelihood of CPAP acceptance, as well as teamwork between experienced technicians and enthusiastic physicians. The numerous potential side effects of CPAP, which include nasal and flow-related problems, skin abrasion, and humidifier issues, can be resolved with appropriate and frequent supervision during the early phase of treatment and including regular long-term reviews. CPAP can improve the cardiovascular, neurocognitive, and renal hepatic consequences of OSA, thus improving longevity and quality of life as well as reducing daytime somnolence. When compared with the recent technique of auto-titrating CPAP (APAP), traditional fixed-pressure CPAP has also been proven to be well accepted in appropriately selected patients. Patient compliance and improvement in daytime sleepiness favor APAP, but fixed-pressure CPAP provides a higher oxygen saturation during sleep. In conclusion, CPAP is the most accepted treatment modality for OSA, but to achieve higher patient acceptance rates and better compliance, research needs to continue into the facial apparatus and delivery methods of the oxygen.

A 47-year-old woman presented to clinic with exertional breathlessness, snoring, choking, witnessed apnoeas and daytime somnolence. Past history included Idiopathic Juvenile Arthritis, diagnosed at age 8, since when she had been taking prednisolone. Her sleep study identified severe Obstructive Sleep Apnoea (OSA). She was commenced on Continuous Positive Airway Pressure (CPAP) therapy, which improved her sleep quality so much that she hardly moved at night and consequently woke up with early morning joint stiffness. She therefore limited her CPAP use and her symptoms persisted. Over time she developed a regime of split-night CPAP use that improved her OSA-related symptoms and joint discomfort.

Studies have investigated the applications of Continuous Positive Airway Pressure (CPAP) therapy in the treatment of hypernasality due to velopharyngeal dysfunction (VPD; Cahill et al., 2004; Kuehn, 1991; Kuehn, Moon, & Folkins, 1993; Kuehn et al., 2002). The purpose of this study was to examine the effectiveness of CPAP therapy to reduce hypernasality in a female subject, post-traumatic brain injury (TBI) and pharyngeal flap, who presented with signs of VPD including persistent hypernasality. Improvements in mean velopharyngeal orifice size, subjective perception of hypernasality, and overall intelligibility were observed from the baseline to 8-week post-treatment assessment intervals. Additional long-term assessments completed at 2, 3, and 4 months post-treatment indicated decreases in immediate post-treatment improvements. Results from the present study suggest that CPAP is a safe, non-invasive, and relatively conservative treatment method for reduction of hypernasality in selected patients with TBI. More stringent long-term follow up may indicate the need for repeated CPAP treatment to maintain results.

In recent years in cardiology actively studied the problem of breathing during sleep in connection with the fact that accumulate more and more data on the value of breathing during sleep in the development of cardiovascular disease, including fatal complications. In particular, great attention is paid to obstructive sleep apnea (OSA), as the condition is most clearly associated with cardiovascular disease. The prevalence of OSAS varies greatly in different study populations, and epidemiological data for Russia are practically absent. As the mechanism responsible for the increase in blood pressure in patients with OSA is usually considered activation of the sympathetic nervous system due to episodes of sleep apnoea. This pathophysiological process is also an important factor in the development of arterial hypertension in obesity. The results of researches, studying the mechanisms of interaction between obesity and OSA, very mosaic. Since OSA sleep much upset and is accompanied by episodes of hypoxia, there is nothing surprising that the secretion of hormones, usually having a circadian daily fluctuations, is also changed. These problems and devoted presented in this article the literature review.

Aims An association between obstructive sleep apnoea (OSA) and atrial fibrillation (AF) has been established. However, studies on the role of OSA in AF recurrence after catheter ablation have yielded conflicting results, and the effect of OSA treatment by continuous positive airway pressure (CPAP) on the success rate of AF catheter ablation is indeterminate. The aim of this meta-analysis was to investigate the rate of AF recurrence after catheter ablation in patients with AF with or without OSA and to evaluate the relationship between CPAP therapy and AF recurrence. Methods and results We performed an online search and identified five studies involving 3743 patients with AF. Patients with OSA had a 31% greater risk of AF recurrence after catheter ablation than did patients without OSA [relative ratio (RR) = 1.31, P = 0.00], and this risk increased by 57% in patients with OSA not undergoing CPAP therapy (RR = 1.57, P = 0.00). However, CPAP users had a risk of AF recurrence similar to that of patients without OSA (RR = 1.25, P = 0.37), and this similarity was maintained even after the removal of study heterogeneity (RR = 0.99, P = 0.39). Conclusion Obstructive sleep apnoea was associated with AF recurrence after catheter ablation. The efficacy of catheter ablation for AF was similar between patients without OSA and patients with OSA undergoing CPAP treatment.

Background and objectiveAlthough positive screening for and treatment of obstructive sleep apnea (OSA) have been recommended for patients with cardiovascular problems, patient adherence to nasal continuous positive airway pressure (CPAP) therapy primarily for a cardiovascular concern is unknown. Therefore, this study aimed to determine the adherence to CPAP therapy by hypertensive patients with OSA after a screening test performed regardless of OSA-related symptoms.Subjects and methodsCPAP therapy was administered to 194 of the 1365 hypertensive patients who underwent the screening. The monthly dropout from CPAP therapy and the adequate use level (4h every night, 70% days in a month) were assessed using the Kaplan–Meier analysis over a 3-year follow-up period.ResultsOf the patients, 106 (55%) refused or abandoned the therapy by the end of the follow-up period (adherence, 45%). An adequate use level was maintained by 76 patients (39%). Most of the patients’ background characteristics, including age, sex, Epworth sleepiness scale scores, and parameters obtained on polysomnography, were not related to adherence or adequate use level. The good-compliance level on the first visit after CPAP therapy introduction was most strongly related to adherence (95% CI, 0.05–0.32; p

For most patients with obstructive sleep apnea syndrome (OSA), continuous positive airway pressure (CPAP) is an effective therapy. However, for a subset of individuals, CPAP is either not effective or is poorly tolerated. Bilevel positive airway pressure (BPAP) is potentially capable of treating OSA at a lower mean pressure than CPAP and can help augment ventilation via pressure support. This review summarizes the evidence for the use of BPAP in spontaneous mode in the initial treatment of patients with OSA and in those who are poorly compliant with CPAP therapy. It also examines evidence regarding use of BPAP in OSA with associated hypoventilation, such as in chronic obstructive pulmonary disease or severe obesity. Finally, current clinical guidelines that help determine which patients would be candidates for a BPAP device and how to manually titrate BPAP to determine the optimal settings to be prescribed are also discussed.

Obstructive sleep apnea (OSA) and obesity are mutually burdening clinical conditions. Weight loss is quite effective for the control of breathing disorders during sleep, but the impact of OSA treatment on the dynamics of body weight in obese patients remains poorly studied. Presented clinical case features a significant reduction in body weight in a patient with morbid obesity complicated by severe OSA with contemporary approach and without CPAP therapy due to high patient adherence to therapy and absence of comorbidities.

The role of leptin in the development of obstructive sleep apnoea (OSA) has been identified. However, the effects of OSA treatment using continuous positive airway pressure (CPAP) on serum leptin levels remain controversial. To address this issue, a meta-analysis was conducted to evaluate the effects of CPAP therapy on serum leptin levels in OSA.A comprehensive literature search was performed to identify studies that focused on the effects of CPAP therapy (treatment duration, ≥4 weeks) on the serum leptin levels of OSA patients. Standardised mean difference (SMD) was used to analyse the summary estimates for CPAP therapy.Fifteen studies involving 427 patients were included in the meta-analysis. Results indicate that the overall SMD of the leptin levels before and after CPAP therapy was 0.137 (95% confidence interval (CI) 0.002 to 0.272); test for overall effect z=1.99 (P=0.046). Sources of heterogeneity were not found by subgroup and meta-regression analyses. Subgroup analyses showed that differences in OSA severity, baseline body mass index, compliance, CPAP duration and leptin assay did not affect the effectiveness of CPAP therapy.The evidence for the use of CPAP therapy on decrease of leptin levels in OSA patients is low, and stronger evidence is needed.

Complex sleep apnea is increasingly recognized as an emerging entity with improved awareness and treatment of obstructive sleep apnea (OSA). This condition may cause continuous positive airway pressure (CPAP) intolerance and persistent symptoms of sleepiness. An high index of suspicion is required to diagnose these subset of patients both during titration and on CPAP therapy. Early recognition of the condition and institution of proper treatment and follow-up measure will improve the CPAP therapy in OSA.

A device was developed to monitor the heart rate of patients who are undergoing CPAP therapy, a technique used to treat Sleep Apnea. This device is a wearable ballistocardiographic device that comprises of a 3-axis gyroscope, embedded into a full face CPAP mask. Data were collected from the gyroscope whilst being worn by a patient in simulated sleeping conditions. From these data, an algorithm was developed to extract heart rate signals from different heart rate estimates from the gyroscope. Over a 5 minute period, the algorithm was able to correctly identify between 64–95% of the heartbeats from the different gyroscope components. In order to improve the accuracy of the heart rate detection, two data fusion algorithms were implemented on the outputs from the heartrate detection algorithm. These two data fusion algorithms involved a custom weighted average algorithm and a Kalman filter, which when applied were able to achieve mean errors of 2.776 beats per minute (STD. 3.279) and 2.349 beats per minute (STD. 2.298) respectively. The performance of these algorithms in the presence of movement artefacts was also tested, and the tests showed that the algorithm is able to recover from large movement artefacts after a short period of between 7–15 seconds. These results show that it is possible to accurately monitor the HR of a subject using signals from a gyroscope embedded into a CPAP mask.

The combination of the obstructive sleep apnea (OSA) syndrome and arterial hypertension (AH) is a common problem affecting both the medical and social aspects of a patient's life. CPAP-therapy is the main treatment of sleep-discorded breathing. This paper focuses on up-to-date data on the relationship between OSA and AH and reviews studies evaluating the effect of CPAP-therapy on blood pressure, the risk of cardiovascular complications and the quality of life of patients.

We report on a rarely documented side effect—tooth movement—associated with positive airway pressure therapy. A 64-year-old woman presented to an orthodontic practice for evaluation of unexplained tooth movement and spaces opening between her anterior teeth. The patient recently received a diagnosis of mild obstructive sleep apnea, for which she had been using continuous positive airway pressure (CPAP) delivered by a nasal pillows interface for the past 18 months. Follow-up questioning revealed that shifting of the teeth was first noticed in the months following the initiation of CPAP and the result of forward thrusting of the tongue during use. Following 12 months of orthodontic treatment, the malocclusion was corrected and teeth returned to their pretreatment positions. Unwanted tooth movement, although a minor sequela, can have a meaningful effect on quality of life. With improved awareness of this issue, the patient experience and ultimately adherence with CPAP treatment can be improved.

CPAP therapy has remained the standard of care for the treatment of sleep apnea for nearly 4 decades. Its overall effectiveness, however, has been limited by incomplete adherence despite many efforts to improve comfort. Conventional alternative therapies include oral appliances and upper airway surgeries. Recently, several innovative alternatives to CPAP have been developed. These novel approaches include means to increase arousal thresholds, electrical nerve stimulation, oral vacuum devices, and nasal expiratory resistive devices. We will review the physiologic mechanisms and the current evidence for these novel treatments.

To predict continuous positive airway pressure (CPAP) adherence at 1 year.We followed consecutive OSA patients scheduled for CPAP initiation for 1 year. Patients completed a self-efficacy questionnaire (5 = low, 25 = high score) before CPAP initiation. After CPAP initiation, we enquired about patients' satisfaction in CPAP trial and their eagerness and willingness to continue CPAP therapy (0 = unsatisfied, uneager, or refused CPAP; 100 = satisfied, eager, or willing to continue CPAP treatment).Of the 580 patients we followed, 377 continued CPAP therapy beyond 1 year. A low willingness score (50) was expressed by 77 patients but only 7 of them used CPAP4 h daily at 1 year, yielding a specificity of 97 % in predicting CPAP failure. At 1 year, patients with a self-efficacy score20, expressed prior to CPAP initiation, used CPAP more often than the patients with a score20 (average use 4.4 ± 2.2 h vs. 3.7 ± 2.3 h, p0.001).A low score of willingness to continue CPAP therapy after a short trial predicts CPAP failure and poor CPAP adherence at 1 year.

BACKGROUND: CPAP is considered to be the cornerstone of therapy for obstructive sleep apnea. However, adherence to this treatment is frequently poor, which may lead to ongoing symptoms, including daytime sleepiness and poor cognitive function. We aimed to determine the efficacy of showing patients their raw graphic polysomnography (PSG) data in increasing their CPAP adherence. METHODS: The subjects were patients with obstructive sleep apnea ( n = 37, diagnosed on prior PSG), who were prospectively randomized into an experimental arm or a control arm. The patients in the experimental arm ( n = 18) were shown detailed PSG data, including graphic data from PSG prior to prescription of CPAP. The patients in the control arm ( n = 19) were shown the non-graphic paper report of the PSG. Adherence data, collected using CPAP devices with internal microprocessors (adherence cards), was read at 4 weeks after treatment initiation. RESULTS: There was no difference in age (57.3 ± 11.8 y vs 55.5 ± 11.6 y, P = .64), body mass index (BMI) (32.7 ± 6.3 kg/m2 vs 32.3 ± 6.6 kg/m2, P = .85), and apnea-hypopnea index (36.0 ± 27.8 events/h vs 30.5 ± 19.1 events/h, P = .48) between the experimental and control arms. There was no difference in percent of days CPAP was used (58% vs 64%, P = .59) and average number of hours each night CPAP was used (3.9 ± 2.1 h vs 4.1 ± 2.5 h, P = .76) between the experimental and control arms, respectively. In multi logistic regression models, which included age, BMI > 30 kg/m2, apnea-hypopnea index, and experimental intervention, only BMI was found to increase likelihood of improved adherence (odds ratio = 13.3, P = .007). CONCLUSIONS: Showing patients raw graphic PSG data does not seem to improve adherence to CPAP. BMI is a very strong predictor of CPAP adherence.

BACKGROUND: The prevalence of obstructive sleep apnea (OSA) increases with age. Treatment often includes CPAP. CPAP adherence is correlated with disease severity and symptoms. We hypothesized that CPAP acceptance rates in elderly patients with OSA would be lower than in younger patients with OSA, and examined factors associated with CPAP acceptance. METHODS: We reviewed the charts of 315 subjects with OSA (apnea-hypopnea index ≥ 5 events/h) who were treated at our hospital from 2008 to 2011 with CPAP therapy. All underwent CPAP titration testing before CPAP prescription. Subjects were grouped by age: young (25–40 y, n = 35), middle-age (41–65 y, n = 169), and elderly (> 65 y, n = 111). Demographic variables, excessive daytime sleepiness, overnight polysomnography study variables, CPAP acceptance, and CPAP adherence were compared. Regression analysis was performed to identify factors associated with acceptance. RESULTS: The elderly subjects had less excessive daytime sleepiness and less pronounced alterations in overnight polysomnography variables than the subjects in the other groups, but had more cardiovascular comorbidities. The CPAP acceptance rate (overall 125/315, 39.7%) was significantly lower in the elderly group, compared with the younger group (31.5% vs 60%, P = .01). CPAP acceptance was associated with fewer comorbidities, higher excessive daytime sleepiness, and higher apnea-hypopnea index, but not age. CPAP adherence was not associated with age. CONCLUSIONS: CPAP acceptance is low in elderly patients in Taiwan. CPAP acceptance, instead of CPAP adherence, is the critical issue with elderly patients with OSA.

Background. Fatigue in patients with multiple sclerosis (MS) is highly prevalent and severely impacts quality of life. Recent studies suggested that sleep-disordered breathing (SDB) significantly contributes to fatigue in MS.Study Objective. To evaluate the importance of routine respirography in MS patients with severe fatigue and to explore the effects of treatment with continuous positive airway pressure (CPAP).Patients and Methods. We prospectively assessed the presence of severe fatigue, as defined by a score of ≥5.0 on the Fatigue Severity Scale (FSS), in 258 consecutive MS patients. Ninety-seven patients (38%) suffered from severe fatigue, whereof 69 underwent overnight respirography.Results. We diagnosed SDB in 28 patients (41%). Male sex was the only independent associate of SDB severity (P=0.003). CPAP therapy in 6 patients was associated with a significant reduction of FSS scores (5.8±0.5versus4.8±0.6,P=0.04), but the scores remained pathological (≥4.0) in all patients.Conclusion. Respirography in MS patients with severe fatigue should be considered in daily medical practice, because SDB frequency is high and CPAP therapy reduces fatigue severity. However, future work is needed to understand the real impact of CPAP therapy on quality of life in this patient group.

Obstructive sleep apnea syndrome (OSAS) is characterized by repeated cessations of breathing during sleep. Most patients suffering from OSAS are treated with continuous positive airway pressure (CPAP) as the first line of therapy. Overall, noncompliance to CPAP can range from 29-83%. In this study of 135 patients, we aimed to evaluate the role of sleep clinics in factors improving adherence to CPAP. Initially, patients had a compliance of 72.6%, but after one year or more overall compliance was 85.9%. Remarkably, the most significant difference was seen in the Medicaid population, whose compliance increased by 26.6%. Considering the well-established benefits of CPAP in patients with OSAS, we determined that a close follow up in a dedicated sleep clinic improves overall compliance especially in the Medicaid population. CPAP mask change was the most successful intervention that improved compliance.

Numerous studies have demonstrated the efficacy of CPAP therapy for reducing symptoms (eg, daytime sleepiness), improving quality of life (QOL), reducing the risk of driving and occupational accidents, and preventing sequelae of obstructive sleep apnea (OSA), such as cardiovascular morbidity and

Aim: Telehealthcare potentially offers an option for remotely monitoring and reviewing people using CPAP therapy. We aimed to systematically review the evidence for the effectiveness of telehealthcare CPAP review verses face-to-face care. Methods: We systematically searched electronic databases plus manual journal searches for clinical trials of telehealthcare for reviewing CPAP users. Two researchers selected, quality appraised and extracted data. Outcomes of interest were adherence to CPAP, subjective sleep, patient/clinician satisfaction, and cost effectiveness. We undertook a narrative analysis because of heterogeneity of outcomes. Results: 5 trials (total 224 patients) met our inclusion criteria. The trials were small at moderate/high risk of bias; the largest randomised 114 patients. Adherence was measured as number of hours used/night (n=3) or proportion using > 4 hours/night (n=2). Telemonitoring (TM) improved adherence to CPAP compared to usual care (UC) in x/5 trials. No reported differences in Epworth Sleepiness score (n=2 trials). 4/5 trials reported similar levels of satisfaction with the clinical review. 2/2 trials reported significant cost reductions with TM compared to UC. Conclusion: A telehealthcare model of clinical review in CPAP shows promise as a cost effective and acceptable model of care, which improved adherence, but not subjective sleepiness. However the evidence is limited to 5 small, generally poor quality studies. Fully-powered, well designed studies are required to prove clinical and cost effectiveness of using available technologies to access specialist sleep services remotely.

Although continuous positive airway pressure (CPAP) is an extremely effective, acceptance & adherence can be difficult. Remote monitoring (RM) may help but little research has been done. The aim of this study was to explore the effectiveness of RM on acceptance & adherence to CPAP therapy. 31 patients were set –up on auto CPAP therapy with RM and reviewed by telephone at 1, 4 & 8 weeks before returning to clinic at 12 weeks. The results were compared with retrospective data from a control group (C) of 27 patients who had been set up on CPAP without RM and returned to clinic after 12 weeks. All subjects received standardized CPAP setup & education & were offered further clinic visits, as required, until a decision of acceptance or decline of treatment was made. We examined the average nightly usage, adherence (% of nights with CPAP use), compliance (% of nights with more than 4 hours use), and rate of acceptance and length of trial. No significant differences in age, gender, AHI or ESS between the two groups. Results are reported as mean±SEM. Daily CPAP usage was significantly longer (504±0.0 vs. 460±0.4 mins; P Remote monitoring is effective at improving nightly CPAP usage and reducing length of trial. Compliance and adherence within CPAP tended to be better with remote monitoring but did not reach a level of statistical significance. Further work is needed to see if a larger sample size will show significant changes.

Background: Positive airway pressure therapy (PAP) is reported to improve the mortality of OSAS with daytime hypercapnia . However, the data on long-term prognosis in hypercapnic OSAS undergoing CPAP therapy are limited. Objective: Our study objectives were to investigate the survival and explore prognostic factors in OSAS with daytime hypercapnia undergoing CPAP therapy. Methods: Thirty-seven patients who were diagnosed OSAS with daytime hypercapnia (PaCO 2 > 45mmHg) were enrolled. All of them are treated with CPAP therapy. The patients were divided into 2 groups according to the improvement of PaCO 2 by CPAP therapy after 3 months (the change in PaCO 2 ≥ 5mmHg; good responder, the change in PaCO 2 Results: During median follow-up of 125 months, All-cause mortality was 33%, in poor responder group to CPAP therapy. In contrast, all of the patients in good responder group survived (log-lank, p = 0.0115). In univariate analysis, patients with PaO 2 2 >45 mmHg at baseline had poor prognosis (p =0.0013, p 2 after CPAP therapy was independent predictor of mortality (p = 0.042). In contrast, neither BMI nor results of pulmonary function tests was linked to their survival. Conclusion: The presence of hypercapnia which is resistant to CPAP therapy predicts poor prognosis in hypercapnic OSAS.

Introduction CPAP therapy is increasingly used in children. Due to the shortage of hospital beds we started an outpatient CPAP initiation program, for a selected population of children with OSAS. Material and Methods Children were included in the outpatient CPAP program if they were in a stable condition, older than 1 year of age, the parents agreed with hospital follow up visits every 2 weeks during the first two months. Results Twelve children were started on CPAP in 2015. shows demographic and treatment adherence data. Only one 16-year-old girl with Down syndrome did not adhere to CPAP. Conclusion Initiating CPAP in children in an outpatient setting in children is feasible in selected patients. Treatment adherence is high and comparable to an inpatient setting.

Introduction: Children with Down Syndrome (DS) are at risk of obstructive sleep apnoea (OSA), with a prevalence of 45-79% (de Miguel-Diez et al. Sleep 2003;26(8):1006-9). Treatment protocols using continuous positive airway pressure (CPAP) for OSA in DS are not dissimilar to the general population. AIM: To evaluate the experience at our institution using CPAP to treat OSA in children with DS Methods: A retrospective review of clinical data for children with DS in whom CPAP therapy was started between 2000-2012 was undertaken. Results: 156 patients with DS had polysomnography (PSG) during this period. 25(16%) children with DS were commenced on CPAP. The mean age at initiation was 8.4yrs (0-17yr). PSG information was available for 16/25 patients(64%) and the mean obstructive apnoea hypopnoea index (OAHI) was 23/hr(2.5-51.2/hr). Titration of CPAP failed in only 3 patients, 2 of who were later re-trialled successfully. Amongst those continuing treatment at home, sustained usage was “poor” ( 6hr/day), 7 transitioned to adult services, 2 improved and discontinued therapy and 1 required escalation to bi-level. Conclusions: CPAP therapy was recommended to treat OSA in a significant proportion of children with DS at our institution over a 12yr period. Only just over 50% of these patients sustained therapy at acceptable levels. This study highlights that CPAP therapy is challenging in this population. Further studies are required to determine if specific interventions or management strategies can improve outcomes.

OBJECTIVE: Previous studies related to evolution of blood pressure (BP) under CPAP therapy in patients with obstructive sleep apnea (OSA) associating hypertension (HT) had a duration of follow up no longer than 12 months. Purpose: To study the variation of 48h BP (using ambulatory blood pressure monitoring ABPM) after 3, 6, 12 and 30 months of CPAP in moderate-severe OSA (PSG) compliant to therapy (CPAP manual titration) and hypertension (HT) under stable antiHT treatment. METHODS: We excluded patients with other sleep pathologies, secondary HT, resistant HT, acute/uncontrolled pathologies, changing medication during the study. RESULTS: 134 patients screened; 7 HT patients (7.42±4.19 years from HT diagnosis) of 96 enrolled with OSA were evaluated at 30 months, 6 men (85.7%). Baseline mean values: age 65.00±12.38 years, BMI 31.38±7.03kg/m 2 , Epworth score 10.28±4.42/h, diagnostic AHI 55.44±29.26/h, oxygen desaturation index70.71±13.30/h, AHI post-titration 10.34±8.89/h, 48h systolic BP (SBP) baseline 147.42±20.2mmHg, diastolic BP (DBP) 78.14±9.22mmHg. In evolution: no changes in BMI or compliance. After 30 months significant improvements (p CONCLUSION: This is the first study that followed compliant OSA and HT patients for 30 months. The study demonstrated reduction in BP much superior to those previously reported, high-lightening the importance in terms of cardiovascular risk of a proper used of CPAP therapy for a long period of time in patients with OSA and HT.

CPAP therapy could have a positive impact on health-related quality of life of elderly patients with OSAhttp://ow.ly/Qxtf305VNa2

J Appl Physiol 120: 1489, 2016; doi:10.1152/japplphysiol.00354.2016. Letter to the Editor Last Word on Viewpoint: Hypercapnia is more important than hypoxia in the neuro-outcomes of sleep-disordered breathing David Wang, 1,2,3,4 Robert J. Thomas, 5 Brendon J. Yee, 1,2,3,4 and Ronald R. Grunstein 1,2,3,4 Sleep & Circadian Group, Woolcock Institute of Medical Research, The University of Sydney, Australia; 2 Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, Australia; 3 NHMRC Centre of Research Excellence in Sleep Medicine-NeuroSleep, Australia; 4 Central Clinical School, The University of Sydney, Sydney, Australia; 5 Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts Address for reprint requests and other correspondence: D. Wang, Woolcock Institute of Medical Research, 431 Glebe Point Road, Glebe NSW 2037, Australia (e-mail: david.wang@sydney.edu.au). http://www.jappl.org ciated neuronal injuries. This is a complex area. Compliant CPAP therapy can generally improve SDB-related neurobe- havioral impairment (2). We reflect that the difference between CPAP and O 2 supplement therapy is that CPAP is more likely to improve hypoxia, hypercapnia, and sleep fragmentation, whereas O 2 supplementation only improves hypoxia. Other comments are generally supportive to our Viewpoint and provided more in-depth exploration of the complex mech- anism between hypoxia-hypercapnia interaction and neural pathophysiology and raised more thought-provoking questions. In research studies, it is important to check 1) is the hypoxia model actually testing the mixed effect of hypoxia and hyper- capnia/hypocapnia? 2) is the hypoxia level comparable to OSA level, particularly for animal studies? The effect of hypercapnia has been long ignored and signif- icantly understudied and it is the time to think beyond hypoxia. Hypercapnia, particularly the interaction between hypoxia and hypercapnia/hypocapnia should be the next frontier of research in SDB neuro-outcomes. Measurement is a key requirement and presents opportunities for cost-effective technological de- velopment. DISCLOSURES No conflicts of interest, financial or otherwise, are declared by the author(s). AUTHOR CONTRIBUTIONS D.W., R.J.T., and R.R.G. conception and design of research; D.W. drafted manuscript; D.W., R.J.T., B.J.Y., and R.R.G. edited and revised manuscript; D.W., R.J.T., B.J.Y., and R.R.G. approved final version of manuscript. REFERENCES 1. Olaithe M, Eastwood PR, Bucks RS, Deacon NL, Malhotra A, Kumar VHS, Zuo L, Chuang CC, Schotland H. Comments on Viewpoint: Hypercapnia is more important than hypoxia in the neuro-outcomes of sleep-disordered breathing. J Appl Physiol; doi:10.1152/japplphysiol.00327.2016. 2. Rosenzweig I, Glasser M, Polsek D, Leschziner GD, Williams SC, Morrell MJ. Sleep apnoea and the brain: a complex relationship. Lancet Resp Med 3: 404-414, 2015. 3. Wang D, Piper AJ, Yee BJ, Wong KK, Kim JW, D’Rozario AL, Rowsell L, Dijk DJ, Grunstein RR. Hypercapnia is a key correlate of EEG activation and daytime sleepiness in hypercapnic sleep-disordered breathing patients. J Clin Sleep Med 10: 517–522, 2014. 4. Wang D, Thomas RJ, Yee BJ, Grunstein RR. Viewpoint: Hypercapnia is more important than hypoxia in the neuro-outcomes of sleep-disordered breathing. J Appl Physiol; doi:10.1152/japplphysiol.01008.2015. 5. Wang D, Yee BJ, Wong KK, Kim JW, Dijk DJ, Duffin J, Grunstein RR. Comparing the effect of hypercapnia and hypoxia on the electroen- cephalogram during wakefulness. Clin Neurophysiol 126: 103–109, 2015. 8750-7587/16 Copyright © 2016 the American Physiological Society Downloaded from http://jap.physiology.org/ by 10.220.33.2 on August 16, 2016 We agree with Olaithe and colleagues (see Ref. 4) that we should never “put hypoxia to bed.” The reason is simple: in clinical sleep-disordered breathing (SDB) scenarios, there are inseparable combinations of repetitive hypoxia and hypercapnia or hypocapnia (ventilatory overshoot mecha- nisms) events. We believe that any SDB neuro-outcomes should consider a combination effect rather than blame hyp- oxia alone, given the evidence we presented. Assuming that measurement challenges applicable to large studies are over- come, novel interactive hypoxia/hypercapnia indices may bet- ter explain the individual vulnerability to SDB neuro-impair- ment. Deacon and Malhotra (1) questioned that our major evidence for the relationship between hypercapnia and neurocognitive deficit was based on hypercapnic SDB patients (3) and most of the OSA patients do not have daytime hypercapnia. We note a lack of reliable and cost-effective widely applicable tools to precisely measure P CO 2 continuously in ordinary OSA patients overnight. We studied hypercapnic SDB patients, which al- lowed us to use the gold standard ABG P CO 2 measurement during wake and there is a wide spectrum of change in P CO 2 after treatment, which makes it possible to correlate with EEG activation change (3). Importantly, to minimize this limitation, we conducted a clinical experiment on normal volunteers to examine the generic effect of hypercapnia and hypoxia (com- parable to levels seen in OSA) on EEG activation (5). Again we found significant correlation between hypercapnia and slowing in EEG, whereas a similar effect was not found with hypoxia alone (Fig. 1 in Viewpoint) (5). This finding is also supported by human brain imaging studies, undersea diver experiments, and a number of animal studies (see Viewpoint, Ref. 4). We agree that most of the OSA patients do not have daytime hypercapnia; they do not have daytime hypoxemia either and that does not exclude hypoxia as a mechanism for SDB related neuro-impairment. More work with less bias to hypoxia is required. Supplemental O 2 does not generally improve SDB neuro- impairment despite improving overnight oxygen saturation; both Deacon and Malhotra and Zuo and Chuang (see Ref. 1) suggest that may be due to irreversible oxidative stress-asso- TO THE EDITOR

Background: Previous studies have suggested that obstructive sleep apnea (OSA) was associated with nonalcoholic fatty liver disease (NAFLD). However, the impact of OSA treatment using continuous positive airway pressure (CPAP) on liver enzymes remained controversial. This meta-analysis was conducted to determine whether CPAP therapy could reduce liver enzyme levels. Methods: Two reviewers independently searched PubMed, Cochrane library, Embase and Web of Science before December 2015. Information on characteristics of subjects, study design and pre- and post-CPAP treatment of serum ALT and AST was extracted for analysis. A total of 5 studies with 7 cohorts that included 192 patients were pooled into meta-analysis. Results: CPAP was associated with a statistically significant decrease on both ALT and AST levels in OSA patients (WMD=8.036, 95% CI=2.788 to 13.285, z=3.00, p=0.003 and WMD=4.612, 95% CI=0.817 to 8.407, z=2.38, p =0.017, respectively). Subgroup analyses indicated that CPAP therapy was more effective in OSA patients with treatment duration>3 months (WMD=12.374, 95% CI=2.727 to 22.020, z=2.51, p=0.012 for ALT and WMD=7.576, 95% CI=1.781 to 13.370, z =2.56, p=0.010 for AST). Conclusion: This meta-analysis suggested that CPAP was associated with a statistically significant decrease on liver enzymes in OSA patients. Further large-scale well-designed RCTs with long-term follow-up are required to clarify this issue. This article is protected by copyright. All rights reserved.

Continuous positive airway pressure (CPAP) has been used for respiratory support in premature infants for more than 40 years and is now a cornerstone of modern neonatal care. Clinical research on CPAP has primarily focused on understanding which devices and pressure sources best implement this therapy. In contrast, less research has examined the optimal duration over which CPAP is administered. We review this aspect of CPAP therapy.

Telemonitoring might enhance continuous positive airway pressure (CPAP) adherence and save nursing time at the commencement of CPAP therapy. We tested wireless telemonitoring (ResTraxx Online System®, ResMed) during the habituation phase of the CPAP therapy in obstructive sleep apnea syndrome (OSAS).In total, 111 consecutive OSAS patients were enrolled. After CPAP titration, patients were followed with the telemonitoring (TM, N = 50) or the usual care (UC, N = 61). The TM group used fixed pressure CPAP device with and the UC group similar device without wireless telemonitoring. Patients and study nurses were unblinded. The evaluated end-points were hours of CPAP use4 h/day, mask leak0.4 L/s, and AHI5/h. Nursing time including extra phone calls, visits, and telemonitoring time was recorded during the habituation phase. CPAP adherence was controlled in the beginning and at the end of the habituation phase and after 1-year of use.TM and UC groups did not differ in terms of patient characteristics. The average length of the habituation phase was 4 weeks in the TM group and fixed 3 months in the UC group. Median nursing time was 39 min (range 12-132 min) in the TM group and shorter compared to that of 58 min (range 40-180 min) (p 0.001) per patient in the UC group. Both treatment groups had high CPAP usage hours (4 h/day) and the change in usage at the end of the habituation phase did not differ between the groups (p = 0.39). Patients in both groups were equally satisfied with the treatment protocol. CPAP adherence (6.4 h in TM vs. 6.1 h in UC group, p = 0.63) and residual AHI (1.3 in TM vs. 3.2 in UC group, p = 0.04) were good in both groups at 1-year follow-up.Wireless telemonitoring of CPAP treatment could be relevant in closing the gap between the increasing demand and available health-care resources. It may save nursing time without compromising short- or long-term effectiveness of CPAP treatment in OSAS.

Upper airway symptom associated with continuous positive airway pressure (CPAP) treatment is an important factor influencing CPAP adherence. There are conflicting data on the effect of a heated humidifier (HH) during CPAP titration for patients with obstructive sleep apnea hypopnea syndrome (OSAHS). This study investigated the effects of HH during CPAP titration in the cool sleeping environment. Forty newly diagnosed OSAHS patients who received CPAP titration in the cool sleeping environment were randomly assigned to HH and non-HH groups. A questionnaire was used to evaluate upper airway symptoms, satisfaction with initial CPAP treatment, and willingness to further use CPAP. Some therapy parameters including leak, apnea hypopnea index (AHI) reduction, and optimal CPAP pressure level were analyzed. We compared these subjective and objective data between the two groups. In subjective sensation, the use of HH can alleviate upper airway symptoms associated with CPAP titration (P

Background: This study is the first to engage Aboriginal Australian and/or Torres Strait Islander peoples (Indigenous Australians) to better understand their experience of treatment for obstructive sleep apnoea (OSA). Objective: To explore Indigenous Australians’ experiences of continuous positive airway pressure (CPAP) treatment, enablers and barriers to CPAP therapy. Methods: A qualitative content analysis was employed. Data were collected by in-depth interviews with 12 Indigenous CPAP users. Results: Lack of knowledge and a sense of shame influence Indigenous health care seeking related to OSA. Support from family and friends is an important factor in influencing the uptake of CPAP therapy and/or persistence with the treatment. Conclusion: Raising awareness about the health risks of untreated OSA and the benefits of treatment will be an important first step for Indigenous Australians to recognise they have a medical condition and to seek treatment.

Aim. Continuous positive airway pressure (CPAP) masks are a key factor in patient compliance. This program assessed the performance of a new nasal pillows mask (NPM) on a variety of new and established obstructive sleep apnea (OSA) patients using CPAP therapy.Methods. Five programs were developed to assess the new NPM [AirFit P10, ResMed] on naïve patients; patients established on another NPM; patients using a nasal mask; patients with low CPAP compliance; and patients who wished to stop using CPAP therapy.Results. A total of 212 patients were included. In naïve patients, CPAP usage after 3 months was5.9±1.7hours/night, compared with the control group at4.6±2.4hours/night (p<0.05). In patients established on another NPM, usage improved to7.4±1.1hours/night versus6.7±1.4(p=0.001). 78% of nasal mask users wished to continue using the new NPM. Low compliance patients improved with an average of 0.87 hours/night (p=0.001) when using the new NPM. In patients at the point of quitting CPAP, 60% continued with therapy using the new NPM. Conclusion. The new NPM mask performed well in a variety of clinical groups of OSA patients receiving CPAP therapy and shows that technical advances in CPAP masks can improve patient compliance.

Obstructive sleep apnea (OSA) is a common medical problem with serious medical consequences if left untreated. Continuous positive airway pressure (CPAP) therapy is the treatment of choice for OSA. However, compliance with CPAP therapy remains a major challenge for patients and practitioners. Therefore, close monitoring and follow-up, support, education, and behavioral therapy are needed to improve CPAP adherence among patients.

Objectives: Due to change in AASM recommended scoring criteria in 2012, we observed that many patients are diagnosed to have moderate-severe OSA and may not need CPAP therapy. We compared AHI derived using AASM recommended scoring definitions in 2007 (AHI2007) and 2012 (AHI2012). We also assessed its impact on prevalence of OSA diagnosis and suggest new OSA classification. Methods: Retrospective review of 290 consecutive patients who underwent in-lab PSG in a tertiary care hospital during a 3 month period. For AHI2007, hypopneas were required to have ≥ 30% airflow reduction and ≥ 4% desaturation; and for AHI2012, hypopneas were required to have ≥ 30% airflow reduction and ≥ 3% desaturation or arousals. Results: Frequency of mild, moderate and severe OSA were 27.6%17.9% 23% vs 23.1%, 22.8%,39.7% using AHI2007 and AHI2012 respectively. This resulted in increased prevalence from 68.6 to 85.5%, diagnosing moderate-severe OSA in 62.5% vs 41% and labeling 21.5% with absent or mild OSA as having moderatesevere disease. An equivalent cut-point of 10, 20, 40 events/hour was explored for AASM 2012 instead of 5, 15, 30 events/hour. Using the new cut-points, prevalence was 71% (vs 85% AHI2012), moderate-severe OSA 45% (vs 62% AHI2012), severe OSA 26% (vs 40% AHI2012) almost comparable to 68.6%, 41% and 23% respectively from AASM 2007. Conclusions: Most studies on OSA used the old scoring and significant associated risks were present in moderate-severe disease. This study demonstrates using AASM 2012, overall prevalence increased and a significant percentage of patients with absent or mild OSA were labeled in higher risks category. This translates to unnecessary CPAP treatment and higher healthcare costs with no significant health benefits for this “false positive” cohort. We suggest consideration to be given to a new cut-point for classification of OSA using AASM 2012.

Obstructive sleep apnea is characterized by intermittent upper airway obstruction during sleep. The most effective treatment is continuous positive airway pressure (CPAP) to keep the airway open. In some cases, severe morning dyspnea is seen just after interruption from CPAP therapy, commonly called deventilation syndrome. This chapter reviews the underlying mechanisms that are still not clarified and how to avoid the syndrome.