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Background The COVID-19 pandemic has caused the relocation of huge financial resources to departments dedicated to infected patients, at the expense of those suffering from other pathologies. Aim To compare clinical features and outcomes in COVID-19 pneumonia and non-COVID-19 pneumonia patients. Patients and methods 53 patients (35 males, mean age 61.5 years) with COVID-19 pneumonia and 50 patients (32 males, mean age 72.7 years) with non-COVID-19 pneumonia, consecutively admitted between March and May 2020 were included. Clinical, laboratory and radiological data at admission were analyzed. Duration of hospitalization and mortality rates were evaluated. Results Among the non-COVID patients, mean age, presence of comorbidities (neurological diseases, chronic kidney disease and chronic obstructive pulmonary disease), Charlson Comorbidity Index and risk factors (tobacco use and protracted length of stay in geriatric healthcare facilities) were higher than in COVID patients. The non-COVID-19 pneumonia group showed a higher (24% vs. 17%), although not statistically significant in-hospital mortality rate; the average duration of hospitalization was longer for COVID patients (30 vs. 9 days, p = .0001). Conclusions In the early stages of the COVID pandemic, our centre noted no statistical difference in unadjusted in-hospital mortality between COVID and non-COVID patients. Non-COVID patients had higher Charlson Comorbidity Scores, reflecting a greater disease burden in this population.Key MessagesIn March 2020, the COVID-19 disease was declared a pandemic, with enormous consequences for the organization of health systems and in terms of human lives; this has caused the relocation of huge financial resources to departments dedicated to infected patients, at the expense of those suffering from other pathologies.Few published reports have compared COVID-19 and non-COVID-19 pneumonia. In our study, performed in a geographic area with a low prevalence of SARS-CoV-2 infection, we found few statistically significant differences in terms of clinical characteristics between the two groups analyzed.In the early stages of the COVID pandemic, our centre noted no statistical difference in unadjusted in-hospital mortality between COVID and non-COVID patients. Non-COVID patients had higher Charlson Comorbidity Scores, reflecting a greater disease burden in this population

Individuals with Chronic Obstructive Pulmonary Disease (COPD) experience sleep disturbances due to the impact of respiratory symptoms on sleep quality. We explored whether sleep disturbances in COPD are linked to heterogeneity of airway constriction.The impact of breathing problems on sleep quality was measured in consecutive COPD outpatients with the COPD and Asthma Sleep Impact Scale (CASIS) questionnaire. Impulse oscillometry technique (IOS) was employed to assess heterogeneity of airway constriction. Subjects with a previous or concomitant diagnosis of asthma or obstructive sleep apnea (OSA) were excluded.Fifty COPD subjects (M/F 40/10; age: 71 +/- 8 yrs, Body Mass Index (BMI): 26.2 +/- 4.7 kg/m(2), Forced Expiratory Volume in the first second (FEV1): 65 +/- 25% predicted; mean +/- SD) were enrolled. The mean CASIS score was 36 +/- 3.3, and the R5-R20 value was 0.2 +/- 0.15 kPa s L-1. The CASIS score was significantly higher in subjects with increased R5-R20 (>0.07 kPa s L-1) (39 +/- 24; p = 0.02) compared to normal R5-R20 (21 +/- 17). When subjects were categorized on the basis of lung function in severely versus non severely obstructed (FEV1 50% predicted) or air trappers versus non air trappers (Residual Volume, RV >= or

Background: Patients on home continuous positive airway pressure (CPAP) or noninvasive ventilation (NIV) show large variability in compliance to treatment. Aim: To identify predictors of poor compliance, we evaluated compliance to treatment in patients with obstructive sleep apnea (OSA), obesity hypoventilation syndrome (OHS), and OSA-chronic obstructive pulmonary disease (COPD) overlap syndrome. Methods: We analyzed clinical and compliance data provided by a single home care provider, in 602 patients (n=442 OSA, males (M) 308; 38 OHS M=15, and 122 overlap M=111) on home CPAP/NIV in the province of Agrigento, Italy, after one year of treatment. The following variables were considered: age, body mass index (BMI), sex, diagnosis, type of prescribed ventilator, and common comorbidities. Results: Mean (±SD) age and BMI were: 64.6±11.9 yrs, and 34.4±7.3 kg/m2. CPAP was prescribed in 67.1%, AutoCPAP in 12.9%, Bilevel in 9.1%, and volume assured pressure support ventilation in 10.9% of the sample. Mean compliance to treatment was 4.7±2.7 h/day, with 64.3% of the patients showing good compliance (>4 h/night). Patients overestimated CPAP/NIV use by 0.5 h/night. Compliance was not affected by age, diagnosis, severity of sleep disordered breathing, type of ventilation or occurrence of comorbidities, with the exception of depression (p=0.05). BMI was higher in poorly compliant compared to compliant patients (p=0.02). When data were split by gender, compliance was OHS>OSAS>overlap in women (p 0.007); overlap>OSAS>OHS in men (p=0.013) Conclusions: A high degree of obesity and depression were associated with poor compliance to ventilatory treatment.

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

Continuous positive airway pressure (CPAP) is the first-choice treatment for obstructive sleep-disordered breathing. Automatic bilevel ventilation can be used to treat obstructive sleep-disordered breathing when CPAP is ineffective, but clinical experience is still limited. To assess the outcome of titration with CPAP and automatic bilevel ventilation, the charts of 356 outpatients (obstructive sleep apnea, n = 242; chronic obstructive pulmonary disease + obstructive sleep apnea overlap, n = 80; obesity hypoventilation syndrome [OHS], n = 34; 103 females) treated for obstructive sleep-disordered breathing from January 2014 to April 2017 were reviewed. Positive airway pressure titration was considered successful in the case of sleep-disordered breathing resolution (apnea-hypopnea index 40 kg/m2(odds ratio 6.16, confidence interval 1.50-25.17, p = 0.011) and CT90% >42% (odds ratio 5.87, confidence interval 1.39-24.83, p = 0.016). During follow-up, automatic bilevel ventilation treatment failed in seven patients (10%), and compliance was similar in CPAP (4.5 ± 2.2 hr) and automatic bilevel ventilation (5.2 ± 2.3 hr, p = 0.09) groups. Automatic bilevel ventilation was useful to treat sleep-disordered breathing, but failed in patients with severe OHS.

Background: Individuals with COPD experience sleep disturbances due to the impact of symptoms on quality of sleep. Aim: To test the hypothesis that, in COPD, sleep disturbances are linked to peripheral airway abnormalities. Methods: An investigational study is being performed at the University of Palermo, Italy. The impact of breathing problems on quality of sleep during the previous week is measured with the COPD and Asthma Sleep Impact Scale (CASIS) questionnaire. Airway resistances by impulse oscillometry (IOS) assesses peripheral airway abnormalities. Lung function evaluation includes static and dynamic lung volume measurements. To rule out the risk of having obstructive sleep apnea, the Epworth Sleepness Scale (ESS) and nocturnal oximetry is performed. Results: To date, 29 COPD subjects (M/F: 25/4, age: 72±8 yrs, BMI: 26.3±4.5 kg/m2, FEV1: 65±11% predicted; mean±SD) have been enrolled. In this interim analysis, the CASIS score was 33 (range: 0-86), and R5-R20 was 0.16±0.09 kPasL-1. Subjects with abnormal peripheral airway resistances (R5-R20>0.07 kPasL-1) had a significantly higher CASIS score than those with R5-R20≤0.07 kPasL-1 (38.9±29 vs 16.6±16, respectively; p=0.049). The CASIS score was not associated with the degree of airway obstruction (FEV1≤50% and >50% predicted: 38±30 vs. 30±27, p=0.48), or the magnitude of air trapping (residual volume >120% and ≤120% predicted: 25±25 vs 39±27, p=0.22). EES and nocturnal oximetry were within normal ranges. Conclusions: Preliminary results indicate that a relationship exists between sleep disturbances due to COPD symptoms and peripheral airway abnormalities. The final analysis will allow better description of this association.

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

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

Obstructive sleep apnea often coexists with visceral adiposity and metabolic syndrome. In this study, we analysed gender-related differences in anthropometrics according to sleep apnea severity and metabolic abnormalities. In addition, the visceral adiposity index, a recently introduced marker of cardiometabolic risk, was analysed. Consecutive subjects with suspected obstructive sleep apnea (n = 528, 423 males, mean age ± standard deviation: 51.3 ± 12.8 years, body mass index: 31.0 ± 6.2 kg m(-2) ) were studied by full polysomnography (apnea-hypopnea index 43.4 ± 27.6 h(-1) ). Variables of general and visceral adiposity were measured (body mass index, neck, waist and hip circumferences, waist-to-hip ratio). The visceral adiposity index was calculated, and metabolic syndrome was assessed (NCEP-ATP III criteria). The sample included controls (apnea-hypopnea index 30 h(-1) , n = 329). When anthropometric variables were entered in stepwise multiple regression, body mass index, waist circumference and diagnosis of metabolic syndrome were associated with the apnea-hypopnea index in men (adjusted R(2) = 0.308); by contrast, only hip circumference and height-normalized neck circumference were associated with sleep apnea severity in women (adjusted R(2) = 0.339). These results changed little in patients without metabolic syndrome; conversely, waist circumference was the only correlate of apnea-hypopnea index in men and women with metabolic syndrome. The visceral adiposity index increased with insulin resistance, but did not predict sleep apnea severity. These data suggest gender-related interactions between obstructive sleep apnea, obesity and metabolic abnormalities. The visceral adiposity index was a good marker of metabolic syndrome, but not of obstructive sleep apnea.

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

it is still debated whether CPAP or non-invasive ventilation (NIV) reduces cardiovascular (CV) risk in morbidly obese patients. Obese subjects affected by obstructive sleep apnea (OSA) or obesity hypoventilation syndrome (OHS) (n=210) were recruited between 2007-2010 in the Sleep Center, Univ. of Grenoble; 152 of them were treated with CPAP or NIV, and regularly followed by a home-care provider (Agir a dom). Patients underwent phone interviews to assess incident CV events during 5.6 years (range 4.0-6.5 yrs) of follow-up. One hundred seventeen patients (63 men) responded to questionnaire, 3 OSA patients died, and 32 declined/were lost to follow-up (response rate 77%). All patients at baseline underwent: clinical examination, respiratory function assessment, full PSG, vascular function (PWV, PAT). Mean (±SD) age and BMI at diagnosis were 53.6±10.7 yr and 40.6±5.7 kg/m 2 . Patients were affected by OSA (n=100) or OHS (n=17); CPAP (n=89) or NIV (n=28) were prescribed. At follow-up, 32 OSA patients had stopped treatment, 57 were on CPAP, and 28 on NIV. Objective compliance to treatment was similar in patients with/without events in both CPAP and NIV groups (mean adherence 6.3 ± 2.4 h/night). Number of events (0-2) was entered as dependent variable in a Poisson regression model in which independent variables were treatment (CPAP or NIV vs interrupted), follow-up duration, and BMI. CPAP showed a protective effect (coefficient: -4.75, p=0.02). Vascular function measurements did not predict events. Thus, CPAP treatment reduced the risk of CV events in severely obese OSA patients. Funded by ERS STRTF 4008-2013.

In cases of morbid obesity, obstructive sleep apnea (OSA) was associated with biopsy-proven liver damage. The role of non-invasive techniques to monitor liver changes during OSA treatment with continuous positive airway pressure (CPAP) is unknown. We used non-invasive ultrasound techniques to assess liver steatosis and fibrosis in severe OSA patients at diagnosis and during long-term CPAP treatment. Fifteen consecutive patients with severe OSA (apnea hypopnea index 52.5 ± 19.1/h) were studied by liver ultrasound and elastography (Fibroscan) at 6-mo (n = 3) or 1-y (n = 12) follow-up. Mean age was 49.3 ± 11.9 y, body mass index (BMI) was 35.4 ± 6.4 kg/m(2). Adherence to CPAP was ≥5 h/night. At baseline, most patients had severe liver steatosis independent of BMI; at follow-up, liver steatosis was not statistically different, but a relationship between severity of steatosis and BMI became apparent (Spearman's rho: 0.53, p = 0.03). Significant fibrosis as assessed by Fibroscan was absent at diagnosis or follow-up (failure or unreliable measurements in four markedly obese patients). Therefore, ultrasound liver assessment is feasible in most OSA patients, and CPAP treatment may positively affect liver steatosis.

Obesity is increasingly recognized as a very complex metabolic state. Besides visceral obesity and white adipose tissue (WAT) function, the most recent studies point to a major metabolic role of brown adipose tissue (BAT) in energy metabolism. Visceral obesity is associated with hypoxia of adipose tissue and inflammation, both these features being also present in patients with obstructive sleep apnea (OSA). Obesity and OSA may share some common pathogenetic mechanisms, since hypoxia and inflammation are major features of OSA as well. However, the unique pattern of intermittent hypoxia occurring in OSA patients during sleep may modify the response of WAT and BAT in both lean and obese subjects. This area is currently being investigated and may provide new insights into the complexity of both obesity and OSA. Finally, sleep disruption or insufficient sleep could further contribute to the metabolic abnormalities of both obesity and OSA.