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Introduction Classic cardiovascular risk factors do not explain all the cardiovascular events. Obstructive sleep apnoea (OSA) has been proposed as a potential and prevalent cardiovascular risk factor. Our study aimed to describe the prevalence of OSA in a middle-aged cohort with mild–moderate cardiovascular risk and evaluate its association with atherosclerotic disease. Methods This is an observational cross-sectional ancillary study of the ILERVAS project which was aimed to study subclinical arterial disease in a cohort with mild–moderate cardiovascular risk. In a sample of consecutive subjects, we performed a sleep study and evaluate OSA prevalence and its association with carotid and femoral atheroma plaques and atherosclerotic burden. Results Overall, 966 subjects with a median age of 57 years (25–75th percentile; 52–62) and a body mass index (BMI) of 28.5 kg/m2 (25.6–31.6) were included. Of these, 72.6% (69.7%–75.3%) had OSA (apnoea–hypopnoea index (AHI) ≥ 5/h); 35.7% (32.8%–38.8%) had mild OSA (AHI 5–14.9/h) and 36.9% (33.9%–39.9%) had moderate/severe OSA (AHI ≥ 15/h). Mean oxygen saturation and the percentage of time with oxygen saturation Conclusions This study confirms a high prevalence of OSA in patients with mild–moderate cardiovascular risk and shows an association between atherosclerotic burden, total and femoral plaque with CT90 and mean oxygen saturation, suggesting the importance of OSA-related hypoxaemia in the induction of atherosclerotic disease.

Rationale: Obstructive sleep apnea (OSA) is associated with poor blood pressure (BP) control and resistant hypertension (RH). Nevertheless, studies assessing its prevalence, characteristics, and association with BP control in patients with RH are limited. Objectives: The aim of this multicenter study was to assess the prevalence of OSA in a large cohort of subjects with RH and to evaluate the association of OSA with BP control. Methods: We recruited consecutive subjects with RH from three countries. A formal sleep test and blood pressure measurements, including 24-hour ambulatory blood pressure monitoring, were performed in all participants. Results: In total, 284 subjects with RH were included in the final analysis. Of these, 83.5% (95% confidence interval [CI], 78.7-87.3%) had OSA (apnea-hypopnea index >= 5 events/h); 31.7% (95% CI 26.5-37.3%) had mild OSA, 25.7% (95% CI, 21-31.1%) had moderate OSA, and 26.1% (95% CI, 21.3-31.5%) had severe OSA. Patients with severe OSA had higher BP values than subjects with mild to moderate or no OSA. A greater effect was observed on the average nighttime BP, with an adjusted effect of 5.72 mm Hg (95% CI, 1.08-10.35 mm Hg) in severe OSA compared with participants without OSA. A dose-response association between the severity of OSA and BP values was observed. The prevalence of severe OSA was slightly higher in uncontrolled participants (adjusted odds ratio, 1.69; 95% CI, 0.97-2.99) but was not statistically significant. Conclusions: The present study confirms the high prevalence of OSA in participants with RH. Furthermore, it shows a dose-response association between OSA severity and BP measurements, especially in the nighttime.

Background A close relationship between obstructive sleep apnoea (OSA) and Alzheimer's disease (AD) has been described in recent years. OSA is a risk factor for AD, but the diagnosis and clinical characteristics of OSA in patients with AD is not well understood. This study evaluated the clinical utility of two screening questionnaires, the STOP-Bang questionnaire (SBQ) and the Berlin questionnaire (BQ), to identify which patients with mild AD are at higher risk of having OSA and to determine the clinical predictors of OSA in this population. Methods In this study, 91 consecutive outpatients with mild AD were prospectively evaluated with the SBQ and the BQ. All patients underwent level 1 in-laboratory polysomnography. The predictive performance of the questionnaires were calculated for different apnoea-hypopnoea index (AHI) cut-offs. Results The median age of the patients was 76.0 (73.0; 80.0) years, and 58 (63.7%) were female. Of those, 81 patients (89.02%) were found to have OSA defined by an AHI > 5 events/h. Comparing the predictive performances of the SBQ and the BQ, the SBQ was found to have a higher diagnostic sensitivity (85% vs 4%), a lower specificity (35% vs. 96%), a higher positive predictive value (PPV) (44% vs 33%) and negative predictive value (NPV) (80% vs 65%) for detecting severe OSA at an AHI cut-off of 30 events/h. None of the items alone in the two questionnaires predicted the risk of OSA. A modified version of the SBQ, with new cut-off points for several variables according to the characteristics of AD patients, showed a slightly greater AUC than the standard SBQ (AUC 0.61 vs 0.72). Conclusion There is a high prevalence of OSA among patients with mild AD. The SBQ and the BQ are not good screening tools for detecting OSA in patients with AD. A modified version of SBQ could increase the detection of these patients.

Patients with type 2 diabetes have been considered a susceptible group for pulmonary dysfunction. Our aim was to assess pulmonary function on the prediabetes stage. Pulmonary function was assessed in 4,459 non-diabetic subjects, aged between 45 and 70 years, without cardiovascular disease or chronic pulmonary obstructive disease from the ongoing study ILERVAS. A “restrictive spirometric pattern”, an “abnormal FEV1” and an “obstructive ventilatory defect” were assessed. Prediabetes was defined by glycosylated hemoglobin (HbA1c) between 5.7 and 6.4% according to the American Diabetes Association criteria. Population was composed of 52.1% women, aged 57 [53;63] years, a BMI of 28.6 [25.8;31.8] kg/m2, and with a prevalence of prediabetes of 29.9% (n = 1392). Subjects with prediabetes had lower forced vital capacity (FVC: 93 [82;105] vs. 96 [84;106], p

We evaluated the influence of untreated obstructive sleep apnoea (OSA) on the magnitude of cognitive decline and on several cognitive subdomains in patients with mild-to-moderate Alzheimer's disease.In this single-centre study, 144 patients were recruited prospectively from a cognitive impairment unit and underwent overnight polysomnography.The mean±sd change in the Alzheimer's Disease Assessment Scale cognitive subscale (ADAS-cog) score at 12 months was 3.19±5.61 in the non-OSA group and 0.08±5.62 in the OSA group, with an intergroup difference of −3.36 (95% CI 0.19–0.16; p=0.002). We did not observe a significant difference in any cognitive subdomains at 12 months. Regarding Mini-Mental State Examination scores at 36 months, the mean change was 1.69 (95% CI −1.26–4.64; p=0.445). No significant differences were found among different OSA severity groups.We observed that ADAS-cog scores were better in the OSA group than in the non-OSA group by a statistically but not clinically significant margin. We did not find differences in the different cognitive subdomains after 1 year or in global cognition after 3 years of follow-up.

Background: Sleep-disordered breathing encompasses a group of diseases, of which obstructive sleep apnea (OSA) is most frequent. Alzheimer's disease (AD) is the most prevalent neurodegenerative disease; it is manifested as an initial deficit of episodic memory that evolves into global cognitive and psychosocial dysfunction, and its prevalence is increasing around the world. OSA has been described as a risk factor for AD, and its prevalence is higher in AD patients. However, little is known about the influence of OSA on cognition in the AD population.The aim of this study was to evaluate the impact of nontreated OSA on the cognitive evolution of patients with mild-moderate AD, to investigate whether the magnitude of the cognitive decline is associated with the severity of OSA and to evaluate the influence of OSA on several cognitive subdomains in AD patients. Methods: In this single-center study, patients with mild-moderate AD were recruited prospectively from a cognitive impairment unit and underwent overnight polysomnography. OSA was defined as an apnea-hypopnea index (AHI) >15/h. AD severity was assessed using the Mini-Mental State Examination (MMSE). The primary outcome was to measure the change in cognitive score on the Alzheimer’s Disease Assessment Scale-cognitive scale (ADAS-cog) from baseline to 12 months in patients with mild AD with and without OSA. An extensive battery of neuropsychological tests, including the Epworth Sleepiness Scale (ESS), were performed and APOE status was measured. Findings: The cohort included 144 patients with a mean (SD) age of 75.19 (5.30) years; 72 (57.6%) were women, and the mean MMSE score was 23.5 (2.24) points at baseline. The mean (SD) change in the ADAS-cog score at 12 months was 3.19 (5.61) in the non-OSA group and 0.08 (5.62) in the OSA group, with a difference between the groups of -3.36 (95%CI 0.19 to 0.16; p=0.002). Regarding the changes in the ADAS-cog subitems at 12 months, ideational praxis, remembering test instructions and commands showed a significant difference between the groups (p

Respiratory failure is a recognized late complication of amyotrophic lateral sclerosis. It is related to the neurological progression of the diseases with the impairment of the respiratory musculature. Survival and quality of life of amyotrophic lateral sclerosis patients is improved by using noninvasive mechanical ventilation. The rate of long-term mechanical ventilation is different within and between countries. Cultural factors, socioeconomic conditions, and physician attitude often influence the decision to start noninvasive ventilation. Technical elements, like the choice of the correct interface, solid caregivers support, and the communication between the patient and the physician are essential for achieving therapeutic goals, especially in the case of continuous treatment.

To assess the prevalence of obstructive sleep apnea (OSA) in patients with mild-moderate Alzheimer’s Disease (AD) and to evaluate cognitive characteristics according to the severity of OSA. Patients with mild-moderate AD, recruited prospectively from a cognitive impairment unit, underwent overnight polysomnography. OSA was defined as an apnea–hypopnea index > 5/h. AD severity was assessed using the Mini-Mental State Examination and extensive neuropsychological battery. Epworth Sleepiness Scale and APOE status were analyzed. The cohort included 128 patients with a median [IQR] age of 75.0 [72.0;79.2] years and 57.8% were women. OSA was diagnosed in 116 subjects (90.6%). The distribution of mild, moderate and severe severity of OSA was 29 (22.7%), 37 (28.9%) and 50 (39.1%), respectively. Regarding sleep symptoms, the cohort showed normal values of daytime sleepiness (median EES score 5 [3, 8]), while nycturia (89.1%) and snoring (71.1%) were the most common symptoms. Participants with severe OSA included a higher proportion of older men, were associated with snoring and sedentariness. No significant differences in cognitive assessment were found between patients with and without severe OSA in any of the domains. The prevalence of APOE e4 was not significantly different between patients with and without severe OSA. There was a high prevalence of OSA in patients with mild-moderate AD. OSA was not associated with sleepiness or worse cognitive function. APOE e4 was not related to the presence or severity of OSA. Further longitudinal studies will be required to evaluate whether OSA impairs cognitive evolution in AD patients.

Subjects with sleep apnea-hypopnea syndrome (SAHS) show an increased carotid intima-media thickness. However, no data exist about earlier markers of atheromatous disease, such as the proliferation and expansion of the adventitial vasa vasorum (VV) to the avascular intima in this setting. Our aim was to assess carotid VV density and its relationship with sleep parameters in a cohort of obese patients without prior vascular events. A total of 55 subjects evaluated for bariatric surgery were prospectively recruited. A non-attended respiratory polygraphy was performed. The apnea-hypopnea index (AHI) and the cumulative percentage of time spent with oxygen saturation below 90% (CT90) were assessed. Serum concentrations of soluble intercellular adhesion molecule 1, P-selectin, lipocalin-2 and soluble vascular cell adhesion molecule 1 (sVCAM-1) were measured. Contrast-enhanced carotid ultrasound was used to assess the VV density. Patients with SAHS (80%) showed a higher adventitial VV density (0.801±0.125 vs. 0.697±0.082, p = 0.005) and higher levels of sVCAM-1 (745.2±137.8 vs. 643.3±122.7 ng/ml, p = 0.035) than subjects with an AHI lower than 10 events/hour. In addition, a positive association exist between mean VV density and AHI (r = 0.445, p = 0.001) and CT90 (r = 0.399, p = 0.005). Finally, in the multiple linear regression analysis, female sex, fasting plasma glucose and AHI (but not CT90) were the only variables independently associated with the mean adventitial VV density (R2 = 0.327). In conclusion, a high VV density is present in obese subjects with SAHS, and chronic intermittent hypoxia is pointed as an independent risk factor for the development of this early step of atheromatous disease.

Introduction: Ventilation with mouthpiece is used since 1990 and there are evidence in literature documenting effectiveness of treatment and increase compliance by the patient. Despite this, there is little knowledge and praticality of the use of non invasive mechanical ventilation (NIV) via a simple mouthpiece. Objective: To evaluate feasibility of mouthpiece ventilation (MPV) in patients with different neuromuscular disease who require NIV and were non compliant. Methods: we treated 3 patient with amyotrophic lateral sclerosis, 1 with Steiner syndrome, 3 with Duchenne dystrophy, 2 with quadriplegia due to spinal cord lesions. All patients were non compliant to NIV and previously refused NIV for claustrophobia, skin breakdowun, conjunctivitis and gastric distension. Each patient was reassessed and was proposed a new trial in NIV with the mouthpiece. Results: All patients tolerated treatment with MPV. The preferred mode was pressure control, inspiratory pressure was set beetween 10- 16, wich ensured an optimal tidal volume (8-10 mL/kg); no back up rate is needed for daytime use so no air blows into the patient9s face. Two patients presented sleep apoea syndrome with secondary respiratory failure, during night time were treated with spontaneous timed mode. Discussion: The mouthpiece should alvays be considered for patient with neuromuscular disease that has to start NIV; it is useful to promote a positive approach and a rapid acceptance of the new condition; it should be considered for patients poorly tolerant to NIV or use NIV many hours a day sometimes alternatin with the nasal or fullface mask. In our experience MPV alone or combined with other interfaces improves the quality of patient9s life and promotes greater adherence to NIV.

Introduction: Patient affected by Duchenne muscular dystrophy does not accept easily the noninvasive mechanical ventilation, due to claustrophobia or anxiety of not being able to call a family member. In our experience appropriate interface selection is crucial for successful NIV. Nasal and oro-nasal masks are the most practical as well as the most commonly used for the NIV. The main limitations of these interfaces are claustrophobia, discomfort and skin lesions. Methods: We evaluated six young patients with Duchenne muscular dystrophy, mean age 18,5 y, who previously had not toleraed NIV. Each patient was reassessed and was proposed a new trial in NIV with the mouthpiece (MPV). Results: All patients tolerated treatment with NIV/MPV. After an initial phase of adaptation to the ventilation mouthpiece during daytime hours, two patients also accept ventilation with nasal mask during the night hours. Conclusion: The use of this interface and MPV modality has allowed us to treat patients who had previously refused nasal, oral or oro-nasal interface for tightness or claustrophobia. Two patients who required NIV overnight, subsequently accepted also the treatment by nasal mask during the night hours. This probably because the use of ventilation mouthpiece during daytime hours improved the feeling of patient safety. This interface should always be considered for patients that has to start NIV; it is useful to promote a positive approach and rapid acceptance of the new condition. Mouthpiece can be very valuable, particularly in patients who use the NIV many hours a day and presenting skin lesions, gastric distension or eye irritation, sometimes alternating with the nasal mask mouth and nose.

Introduction: In pediatrics, the efficacy of weaning protocols is still controversial because the information reported is less consistent, so that as there are not yet reliable criteria for weaning and extubation. The aim of this study is to evaluate the use of low-level BCPAP in the weaning process from invasive mechanical ventilation (IMV) in infants with chronic respiratory failure (CRF) secondary to congenital heart disease, after cardiac surgical correction. Methods: We studied 12 critically ill infants, aged between 3 and 20 months with CRF, univenticular congenital heart disease surgically corrected, on IMV with SIMV mode, through tracheostomy tube. It was not possible to wean them according to classical procedures. We performed the weaning process with the progressive increase of the diameter of the cannula and the progressive reduction of pressure support and acts in SIMV mode, while spontaneous breathing cycles were performed with BCPAP. Results: The patients had a median stay of 48 days in the intensive care unit (ICU). In particular, ten patients presented respiratory infection. For them the endotracheal tube was utilized for a median of 25 days. Two patients didn9t present infectious complication. They underwent endotracheal IMV for a median of 18.5 days. All patients received BCPAP for a median of 14 days. The lightweight BCPAP system didn9t present tube obstructions or accidental decannulations. Conclusion: BCPAP is well tolerated in critical infants on IMV and can reduce the duration of ventilation weaning process and ICU stay, without severe complications.

Introduction: often, asthma and sleep apnea syndrome coexist; the overlap of the two diseases makes necessary the treatment of both conditions. Objective: to evaluate the effects of bronchodilator therapy on nocturnal non invasive ventilation (NIV) in patients with asthma and sleep apnea syndrome. Methods: we studied diurnal and nocturnal respiratory function in 45 patients with asthma and sleep apnea syndrome moderate/ severe. Patients were subjected to polysomnography in NIV. These patients received obstructive sleep apnea test (OSAS test) and asthma control test (ACT). Bronchodilator therapy was optimized according to GINA guidelines, and after 30 days, we revaluated patients with new polysomnography and OSAS and ACT test. Results: the data showed that 60% of patients had poor control of symptoms and poor adherence to therapy night with an average time of use of the device 4 hours per night, SpO2 average of 93%, index of desaturation/hour of 16.2. Conclusions: patients affected by asthma in comorbidity with sleep apnea, have a worse quality of life for the coexistence of similar symptoms; Because of the increasing number of patients with overlap syndrome, the correct treatment of asthma, and nocturnal syndrome overlapped is the only valid therapeutic option. Bronchodilator therapy unoptimized can interfere with therapy in NIV, and if not, therefore, encourage adherence to NIV and improve their effectiveness.

NIV therapy of OSAS has been shown to improve left ventricular (LV) systolic dysfunction, also due to a reduction in LV afterload and causes a regression of LV hypertrophy. However, the effect of NIV on the patterns of right heart function and geometry are less well known. The aim of the study was to analyze the different involvement of right heart function in patients with OSAS treated with NIV by the use of 2D-STE, a novel approach to provides accurate information about segmental myocardial deformation during the cardiac cycle. We enrolled 20 subject with OSAS. Exclusion criteria were coronary disease, valvular heart disease, congestive heart failure, cardiomyopathies. All the patients underwent sleeping NIV for at least 12 hours. Echocardiogram was made pre- and during NIV. Inferior Caval Vein both inspiration and expiration was higher during ventilation (p The study demonstrates that a novel speckle-tracking algorithm represent a promising non-invasive technique to assess RV myocardial function in patients with OSAS during NIV and also highlights the worsering of the function of the right heart during NIV, probably due to the increase of afterload. This suggests to carefully assess the myocardial function before starting NIV in patients with high suspect of the right heart impairment.

Introduction: Patients affected by glycogenosis type II, also Pompe disease, are susceptible to the development of sleep disordered breathing. Symptoms suggestive of sleep disordered breathing often can be underestimated. Objective: To evaluate sleep disordered breathing and nocturnal respiratory pattern in patients affected by glycogenosis type II. Methods: We examined in a group of ten patients, affected by glycogenosis type II, adult and juvenile form, the presence of symptoms suggestive of sleep-disordered breathing with a questionnaire. Diurnal respiratory function, diaphragm weakness and nocturnal respiratory pattern were evaluated at the enrolment. In patients presenting sleep disordered breathing, the same parameters were re-evaluated after treatment with assisted non invasive ventilation. Results: Out of 10 patients, 5 presented symptoms suggestive of sleep-disordered breathing at the baseline, 2 a pattern of sleep apnea syndrome and 3 nocturnal hypoventilation. All patients presented diaphragmatic weakness. No correlation was found between forced vital capacity values in sit position and nocturnal respiratory disorders. Five patients with respiratory disorders were treated with non invasive ventilation. All patients – after one month of treatment - showed an improvement in symptoms with reduced diurnal hypersomnia, absence of morning headaches and nocturnal awakenings, and reduced nicturia regardless the modality of ventilation. Conclusions: We suggest that all patients with glycogenosis type II, once diagnosed, are carefully monitored for the development of respiratory involvement, even in the absence of reduced forced vital capacity values and also in the early stages of the disease.

Undiagnosed obstructive sleep apnoea is common in patients with medically refractory epilepsy. The aim of this study is to evaluate sleep alterations and the prevalence of Sleep Breathing Disorders (SBD) in a paediatric population with catastrophic epileptic encephalopathy. To diagnose SBD, polysomnography (PSG) was performed in eleven patients (nine males, two females), with ages ranging between 3 and 11 years old, with epileptic encephalopathy characterized by drug-resistant seizures, occurring both in sleeping and waking, mental retardation and cerebral palsy. All the patients presented alterations of the sleep architecture and were positive for SBD. In particular, seven patients presented a severe form of Obstructive Sleep Apnoea Syndrome (OSAS) with apnoea/ hypopnea index (AHI) greater than10/hr, two patients presented a moderate form with AHI between 5/hr and 10/hr, two patients presented a mild form with AHI lower than 4/hr. In conclusion, SBD and sleep disruption appeared to be in comorbidity with catastrophic epileptic encephalopathy. Their treatment might also have a positive impact in seizures control and quality of life.

A few studies showed that both adherence to Mediterranean diet (MedDiet) and physical activity practice have a positive impact on pulmonary function in subjects with lung disease. These associations are not well studied in subjects free from lung disease. In a cross-sectional study conducted in 3020 middle-aged subjects free of lung disease, adherence to the MedDiet using the Mediterranean Diet Adherence Screener, and physical activity practice using the International Physical Activity Questionnaire short form were recorded. Respiratory function was assessed using forced spirometry and the results were evaluated according to the Global initiative for Chronic Obstructive Lung Disease. Logistic regression models were used to analyze the associations between adherence to the MedDiet and physical activity practice with the presence of ventilatory defects. Participants with a high adherence to MedDiet, in comparison to those with low adherence, had both higher forced vital capacity (FVC, 100 (87&ndash, 109) vs. 94 (82&ndash, 105) % of predicted, p = 0.003) and forced expired volume in the first second (FEV1, 100 (89&ndash, 112) vs. 93 (80&ndash, 107) % of predicted, p &lt, 0.001). According to their degree of physical activity, those subjects with a high adherence also had both higher FVC (100 (88&ndash, 107) vs. 94 (83&ndash, 105) % of predicted, p = 0.027) and FEV1 (100 (89&ndash, 110) vs. 95 (84&ndash, 108) % of predicted, p = 0.047) in comparison with those with low adherence. The multivariable logistic regression models showed a significant and independent association between both low adherence to MedDiet and low physical activity practice, and the presence of altered pulmonary patterns, with differences between men and women. However, no joint effect between adherence to MedDiet and physical activity practice on respiratory function values was observed. Low adherence to MedDiet and low physical activity practice were independently associated with pulmonary impairment. Therefore, the lung mechanics seem to benefit from heart-healthy lifestyle behaviors.