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Benefiting from advancements in algorithms and computing capabilities, supervised deep learning models offer significant advantages in accurately mapping individual tree canopy cover, which is a fundamental component of forestry management. In contrast to traditional field measurement methods, deep learning models leveraging remote sensing data circumvent access limitations and are more cost-effective. However, the efficiency of models depends on the accuracy of the tree crown annotations, which are often obtained through manual labeling. The intricate features of the tree crown, characterized by irregular contours, overlapping foliage, and frequent shadowing, pose a challenge for annotators. Therefore, this study explores a novel approach that integrates the annotations of multiple annotators for the same region of interest. It further refines the labels by leveraging information extracted from multi-spectral aerial images. This approach aims to reduce annotation inaccuracies caused by personal preference and bias and obtain a more balanced integrated annotation.

Background: Obstructive sleep apnoea (OSA) is associated with hypertension, and OSA treatment can reduce systolic blood pressure (SBP) and diastolic blood pressure (DBP), but with a modest mean effect size and vast heterogeneity among studies. The aim of this individual patient data (IPD) meta-analysis was to understand which OSA phenotypes could benefit the most in terms of BP reduction., Methods: A systematic review of randomised controlled trials that compared continuous positive airway pressure (CPAP) with either passive or active treatment was conducted. Studies were eligible if they included adult patients with OSA diagnosed by full polysomnography or cardiorespiratory polygraphy (defined as apnoea-hypopnoea index >5 events·h -1 ) and if BP was measured both before and after CPAP treatment., Results: In total, 36 parallel studies (n=9434 patients) were included. CPAP treatment was associated with BP reduction in patients with uncontrolled office SBP only, while BP was not reduced by CPAP in patients with controlled BP (SBP -2.6 versus 0 mmHg; p<0.0001; DBP -1.7 versus -1 mmHg; p=0.091). Differences were seen also when BP changes were compared between patients aged ≤60 versus >60 years after multiple imputation only (p=0.0127 for SBP and p=0.017 for DBP). No differences were seen in terms of BP reduction when comparing patients with/without severe nocturnal hypoxia., Conclusions: This IPD meta-analysis of the BP effects of OSA treatment with CPAP shows that OSA patients with uncontrolled BP at baseline benefit the most from CPAP therapy in terms of BP reduction. These results have important implications for the decision on how to best manage arterial hypertension associated with OSA., Competing Interests: Conflict of Interest: E.I. Schwarz reports grants from Löwenstein Medical AG, Philips and LUNGE Zürich. P.A. Cistulli reports grants or contracts from ResMed, ResMed Foundation and SomnoMed for the provision of grant funds or equipment for investigator-initiated research, consulting fees from ResMed (paid to institution), and SomnoMed, Signifier Medical, Bayer and Sunrise (paid to consultant), and payment or honoraria for lectures, presentations, speakers bureaus, manuscript writing or educational events from SomnoMed (paid to speaker). L.F. Drager reports grants from FAPESP (Brazilian Funding Agency; grant 2019/23496-8) and consulting fees from ResMed (consultant for real-world data on PAP telemonitoring). C. Fava reports payment or honoraria for lectures, presentations, manuscript writing or educational events from Menarini and Novartis. M.S.M. Ip reports grants from Li Ka Shing Foundation. T. Quinnell reports grants from the UK NIHR for the PAPMAT study, with payments to their institution only, fees for an educational talk on sleep apnoea at Cambridge University Medical School, and a consultancy agreement with Jazz Pharma UK Ltd that included services in return for registration, accommodation, travel and subsistence at the World Sleep Conference in Rome; T. Quinnell is the President and then Past President of the British Sleep Society (unpaid), and the Chair of the Sleep Apnoea Specialty Advisory Group for the British Thoracic Society, and is also the Director of their own company, TNQ Medical Ltd, where they conduct private medical work. The remaining authors have no potential conflicts of interest to disclose., (Copyright ©The authors 2025. For reproduction rights and permissions contact permissions@ersnet.org.)

Sniff nasal inspiratory pressure (SNIP) is used to assess respiratory muscle strength in neuromuscular diseases like amyotrophic lateral sclerosis (ALS). The effect of contralateral nostril occlusion and mouth sealing on SNIP measurement are unclear. 81 participants were included (16 healthy, 39 patients with limb-onset ALS and 26 patients with bulbar-onset ALS). SNIP was obtained with combinations of mouth open/sealed and contralateral nostril open/occluded. Occluding the contralateral nostril (with mouth closed) increased SNIP by 12 cmH 2 O (95% CI 4, 20; p=0.003) in the healthy participants, by 9 cmH 2 O (95% CI 5, 12; p<0.001) in the limb-onset cohort and by 10 cmH 2 O (95% CI 5, 14; p<0.001) in the bulbar-onset cohort. Opening the mouth decreased SNIP by 19 cmH 2 O (95% CI 5, 34; p<0.009) in healthy participants, by 8 cmH 2 O (95% CI 4, 13; p<0.001) in the limb-onset cohort and by 13 cmH 2 O (95% CI 7, 19; p<0.001) in the bulbar-onset cohort. With contralateral nostril occlusion, 11% fewer individuals would have qualified for non-invasive ventilation. In conclusion, contralateral nostril occlusion increased SNIP compared with standard technique, likely reflecting true strength. Opening the mouth reduced SNIP, emphasising the need for good mouth sealing. Documenting SNIP technique is important for longitudinal assessments and clinical decision-making., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2025. No commercial re-use. See rights and permissions. Published by BMJ Group.)

Sleep Related Painful Erections (SRPE) are parasomnias exclusive to Rapid Eye Movement (REM) sleep, causing sleep disturbances, daytime fatigue, and impaired quality of life. Due to a lack of standardized management, we developed a diagnostic and treatment pathway for this rare condition at our institution. Patients diagnosed with SRPE from 2017-2024 by strict criteria were recruited into our novel pathway. This included a comprehensive diagnostic panel to exclude potential confounding causes of penile pain through history, clinical examination, laboratory tests and imaging studies. Once SRPE is diagnosed a stepwise approach of initiating Baclofen (10 mg daily at night), followed by polysomnography (PSG) (to explore sleep architecture and implement sleep medication and/or treat obstructive sleep apnoea accordingly) and pelvic floor physiotherapy (PFP) (to target pelvic floor hypertonicity). Symptoms were evaluated using a dedicated questionnaire during clinic follow-up. Patients achieving a symptom-free period of >6 months were discharged. Twenty patients with SRPE (mean age 46.2 ± 11.6 years) were included. The mean delay to referral was 3.5 ± 3.1 years, with a mean of 3.3 ± 2.1 SRPE episodes per night (range 1-7) lasting 33 ± 23.7 minutes. 85% of patients completed most of the pathway. Baclofen was administered to 17 patients (10-80 mg at night), 17 underwent PSG, and 9 had PFP assessment. Baclofen benefited 70.6% of patients: 35.3% managed with Baclofen alone, 52.9% required additional sleep medication, and Baclofen was replaced by Etilefrine (5-15 mg at night) in 11.8%. PSG findings included fragmented sleep (76.5%), REM sleep abnormality (47.1%), and mild sleep apnoea (41.2%). Among those assessed for PFP, 66.6% had abnormal pelvic floor muscle tone and initiated PFP. After 3.5 ± 1.9 years of follow-up, 45% were successfully discharged and 55% are still on follow-up and experienced symptom improvement. This multimodal pathway offers a promising framework for managing SRPE., Competing Interests: Competing interests: The authors declare no competing interests. Ethical approval: This research was undertaken as part of a service improvement project, approved by GSTT audit committee, project number (8431). Informed consent was obtained from all participants, and we rigorously adhered to the ethical guidelines and regulations outlined in the editorial policy section, prioritizing the protection of participants’ rights, confidentiality, and welfare throughout the entire process., (© 2024. The Author(s), under exclusive licence to Springer Nature Limited.)

There is an ongoing debate in the United Kingdom and in other countries about whether twice-yearly changes into and out of Daylight Saving Time should be abolished. Opinions are divided about whether any abolition of Daylight Saving Time should result in permanent Standard Time, or year-long Daylight Saving Time. The British Sleep Society concludes from the available scientific evidence that circadian and sleep health are affected negatively by enforced changes of clock time (especially in a forward direction) and positively by the availability of natural daylight during the morning. Thus, our recommendation is that the United Kingdom should abolish the twice-yearly clock change and reinstate Standard Time throughout the year., (© 2024 The Author(s). Journal of Sleep Research published by John Wiley & Sons Ltd on behalf of European Sleep Research Society.)

Background: Obstructive sleep apnoea (OSA) is the most common sleep-related breathing disorder. Non-invasive ventilation (NIV) is essential for managing hypercapnic respiratory failure in patients with obesity hypoventilation syndrome (OHS) and those with co-existing OSA, where continuous positive airway pressure (CPAP) alone is insufficient. However, adherence to NIV can be challenging, with substantial non-compliance occurring due to factors such as discomfort and phobia. The objective of this protocol is to assess the improvement of adherence to NIV remotely monitored, as well as to record symptom control and long-term clinical outcomes, and to optimise healthcare resource usage., Methods: This is a prospective, randomised, and controlled (usual care) trial with a two-arm parallel group design, testing remote monitoring of home NIV (T4P device, SRETT, Paris, France) for 3 months in patients with OSA/OHS who have previously had low NIV adherence (<4 hours/night). This project has been approved by the research ethics committee/Health Research Authority (HRA) [Integrated Research Application System (IRAS) ID: 270108], as well as by Guy's & St Thomas' NHS Foundation Trust R&D Department., Discussion: Outcomes will be compared between the intervention and the control group (NIV with vs. without remote monitoring). The trial will also assess suitability of the outcome parameters, and test whether the data collection, symptom questionnaires, and used healthcare resources are suitable to describe the impact on patient-related outcomes., Trial Registration: This study is registered at ClinicalTrials.gov (NCT04884165)., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-24-86/coif). The series “Sleep Section” was commissioned by the editorial office without any funding or sponsorship. J.S. serves as an unpaid editorial board member of Journal of Thoracic Disease. The authors have no other conflicts of interest to declare., (2024 AME Publishing Company. All rights reserved.)

Many patients with obstructive sleep apnoea (OSA) remain undiagnosed and thus untreated, and in part this relates to delay in diagnosis. Novel diagnostic strategies may improve access to diagnosis. In a multicentre, randomised study, we evaluated time to treatment decision in patients referred for suspected OSA, comparing a mandibular movement (MM) monitor to respiratory polygraphy, the most commonly used OSA detection method in the UK. Adults with high pre-test probability OSA were recruited from both northern Scotland and London. 40 participants (70 % male, mean±SD age 46.8 ± 12.9 years, BMI 36.9 ± 7.5 kg/m 2 , ESS 14.9 ± 4.1) wore a MM monitor and respiratory polygraphy simultaneously overnight and were randomised (1:1) to receive their treatment decision based on results from either device. Compared to respiratory polygraphy, MM monitor reduced time to treatment decision by 6 days (median(IQR): 13.5 (7.0-21.5) vs. 19.5 (13.7-35.5) days, P = 0.017) and saved an estimated 29 min of staff time per patient., Competing Interests: Declaraton of competing interest MJM discloses being a co-applicant on a European Institute of Innovation & Technology grant, developing e-health and integrated care. MIP discloses being a paid consultant for Philips Respironics. JLK discloses speaking fees from Sunrise SA., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Adherence to Continuous Positive Airway Pressure (CPAP) for obstructive sleep apnoea (OSA) can be improved by behavioural interventions which modify patients' beliefs and cognitions about OSA, CPAP, and themselves. We have conducted the first systematic review of the literature on beliefs and cognitions held before starting treatment, and personality (which influences the former) that predict the decision to purchase or start CPAP, or CPAP adherence one month or more after CPAP initiation. A systematic search and screen of articles identified 21 eligible publications from an initial 1317. Quality assessment performed using an adapted Newcastle-Ottawa Scale demonstrated that 13 (62%) studies were poor quality and only seven (33%) were high quality. Eighteen factors, such as self-efficacy (confidence) in using CPAP and value placed on health predicted CPAP adherence; however, for only six (33%), utility as an intervention target is known, from calculation of individual predictive power. Studies did not use new behavioural frameworks effective at explaining adherence behaviours, nor did they interview patients to collect in-depth data on barriers and facilitators of CPAP use. Future studies cannot have these limitations if high quality evidence is to be generated for intervention development, which is currently sparse as highlighted by this review., Competing Interests: Declaration of competing interest None to declare., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Chronic respiratory disease can exacerbate the normal physiological changes in ventilation observed in healthy individuals during sleep, leading to sleep-disordered breathing, nocturnal hypoventilation, sleep disruption and chronic respiratory failure. Therefore, patients with obesity, slowly and rapidly progressive neuromuscular disease and chronic obstructive airways disease report poor sleep quality. Non-invasive ventilation (NIV) is a complex intervention used to treat sleep-disordered breathing and nocturnal hypoventilation with overnight physiological studies demonstrating improvement in sleep-disordered breathing and nocturnal hypoventilation, and clinical trials demonstrating improved outcomes for patients. However, the impact on subjective and objective sleep quality is dependent on the tools used to measure sleep quality and the patient population. As home NIV becomes more commonly used, there is a need to conduct studies focused on sleep quality, and the relationship between sleep quality and health-related quality of life, in all patient groups, in order to allow the clinician to provide clear patient-centred information., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: CPAP is the "gold standard" treatment for obstructive sleep apnea (OSA). Current CPAP models have developed additional functions including automatic CPAP and pressure relief. However, CPAP adherence has not improved over the last three decades. Many patients in low-income countries cannot afford these CPAP devices. A novel simple CPAP device with a fixed pressure without pressure controller was developed., Methods: Manual CPAP pressure titration was performed in 127 patients with OSA. Six patients with a titration pressure higher than 11 cmH 2 O and 14 patients who could not tolerate CPAP were excluded, leaving 107 participating in the following 2 studies. In study one, 54 of 107 patients were treated by both conventional fixed CPAP and simple CPAP in random order. In the second study, another 53 patients were treated by both autoCPAP in automatic function and simple CPAP in random order. Simple CPAP was fixed at 10 cmH 2 O, 8 cmH 2 O, and 6 cmH 2 O for patients whose titration pressure was between 9-10, 7-8, and ≤ 6 cmH 2 O, respectively. Conventional fixed CPAP device was set exactly the same as manual titration pressure., Results: All patients whose manual titration pressure ≤ 10 cmH 2 O were effectively treated by simple CPAP (AHI 40.7 ± 2.3 events/h before vs 2.5 ± 0.3 events/h after, p < 0.001). Patients expressed similar preferences for simple CPAP, autoCPAP, and conventional fixed CPAP (p > 0.05)., Conclusions: We conclude that a novel simple CPAP is an alternative treatment for most patients with OSA, which may widen access to CPAP therapy in the developing countries because of its low cost., (© 2023. The Author(s).)

CO 2 inhalation has been previously reported as a treatment for central sleep apnea both when associated with heart failure or where the cause is unknown. Here, we evaluated a novel CO 2 supply system using a novel open mask capable of comfortably delivering a constantly inspired fraction of CO 2 ([Formula: see text]) during sleep. We recruited 18 patients with central sleep apnea (13 patients with cardiac disease, and 5 patients idiopathic) diagnosed by diaphragm electromyogram (EMG) recordings made during overnight full polysomnography (PSG) ( night 1 ). In each case, the optimal [Formula: see text] was determined by an overnight manual titration with PSG ( night 2 ). Titration commenced at 1% CO 2 and increased by 0.2% increments until central sleep apnea (CSA) disappeared. Patients were then treated on the third night ( night 3 ) with the lowest therapeutically effective concentration of CO 2 derived from night 2 . Comparing night 1 and night 3 , both apnea-hypopnea index (AHI; 31 ± 14 vs. 6 ± 3 events/h, P < 0.01) and arousal index (22 ± 8 vs. 15 ± 8 events/h, P < 0.01) were significantly improved during CO 2 treatment. Sleep efficiency improved from 71 ± 18 to 80 ± 11%, P < 0.05, and sleep latency was shorter (23 ± 18 vs. 10 ± 10 min, P < 0.01). Heart rate was not different between night 1 and night 3 . Our data confirm the feasibility of our CO 2 delivery system and indicate that individually titrated CO 2 supplementation with a novel device including a special open mask can reduce sleep disordered breathing severity and improve sleep quality. Randomized controlled studies should now be undertaken to assess therapeutic benefit for patients with CSA. NEW & NOTEWORTHY A novel device using a special mask was developed and proved that CO 2 therapy using the device could eliminate central sleep apnea (CSA) events and improve sleep quality including reducing arousal index in patients with heart failure. The device would become a useful clinical treatment for heart failure patients with CSA.

Background: The sleep onset process is an ill-defined complex process of transition from wakefulness to sleep, characterized by progressive modifications at the subjective, behavioural, cognitive, and physiological levels. To this date, there is no international consensus which could aid a principled characterisation of this process for clinical research purposes. The current review aims to systemise the current knowledge about the underlying mechanisms of the natural heterogeneity of this process., Methods: In this systematic review, studies investigating the process of the sleep onset from 1970 to 2022 were identified using electronic database searches of PsychINFO, MEDLINE, and Embase., Results: A total of 139 studies were included; 110 studies in healthy participants and 29 studies in participants with sleep disorders. Overall, there is a limited consensus across a body of research about what distinct biomarkers of the sleep onset constitute. Only sparse data exists on the physiology, neurophysiology and behavioural mechanisms of the sleep onset, with majority of studies concentrating on the non-rapid eye movement stage 2 (NREM 2) as a potentially better defined and a more reliable time point that separates sleep from the wake, on the sleep wake continuum., Conclusions: The neurophysiologic landscape of sleep onset bears a complex pattern associated with a multitude of behavioural and physiological markers and remains poorly understood. The methodological variation and a heterogenous definition of the wake-sleep transition in various studies to date is understandable, given that sleep onset is a process that has fluctuating and ill-defined boundaries. Nonetheless, the principled characterisation of the sleep onset process is needed which will allow for a greater conceptualisation of the mechanisms underlying this process, further influencing the efficacy of current treatments for sleep disorders., Competing Interests: Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://jtd.amegroups.com/article/view/10.21037/jtd-23-325/coif). The series “Clinical Update Sleep 2023” was commissioned by the editorial office without any funding or sponsorship. JS serves as the unpaid Guest Editor of the series and an unpaid editorial board member of Journal of Thoracic Disease. DOR reports that he has received honoraria for lectures, presentations and articles from: Neurodiem, TEVA, British Association of Psychopharmacology and Idorsia. He is on the advisory panel for the MRC Circadian Mental Health Network. He has insomnia-related patents with Closed Loop Medicine, with whom he has stock options (as a former employee). He is the current president of the Sleep Medicine Section at the Royal Society of Medicine, London. The other authors have no conflicts of interest to declare., (2023 Journal of Thoracic Disease. All rights reserved.)

Respiratory waveforms can be reduced to simple metrics, such as rate, but this may miss information about waveform shape and whole breathing pattern. A novel analysis method quantifying the whole waveform shape identifies AECOPD earlier. https://bit.ly/3M6uIEB., Competing Interests: Conflict of interest: M. Nandi and P.J. Aston are coinventors of SPAR method – Delay coordinate analysis of periodic data, patent number WO2015121679A1, used in this study. Conflict of interest: N. Hart is involved in an investigator-led/industry-funded trial (unrestricted grant) with Resmed. He receives consulting fees from Philips for a hospital patient monitoring programme. He has received payments and honoraria from Fisher and Paykel (chairing an ERS International Congress 2022 symposium) and Philips (lecturing at an ERS International Congress 2022 symposium). He has received financial support for attending meetings from Fisher and Paykel (ERC 2022). He has patents planned, issued or pending for Myotrace (held by Guy's and Thomas’ Foundation Trust). Conflict of interest: R.F. D'Cruz receives consulting fees from Resmed and AstraZeneca. She receives payment or honoraria for lectures, presentations, speakers’ bureaus, manuscript writing or educational events from Fisher Paykel and Resmed. She receives support for attending meetings from Fisher Paykel and Resmed. Conflict of interest: M. Serna-Pascual, M. Volovaya, C.J. Jolley, G.F. Rafferty and J. Steier have declared no conflict of interest., (Copyright ©The authors 2023.)

Introduction: Just under half of patients with obstructive sleep apnoea (OSA) also have gastro-oesophageal reflux disease (GORD). These conditions appear to be inter-related and continual positive airway pressure (CPAP) therapy, the gold standard treatment for OSA to prevent airway collapse, has been shown to reduce GORD. As the impact of mandibular advancement devices, a second-line therapy for OSA, on GORD has yet to be investigated, a feasibility study is needed prior to a definitive trial., Methods: This will be a single-centre, single-blinded, tertiary-care based, interdisciplinary, parallel randomised controlled study. Potential OSA participants presenting to the sleep department will be pre-screened for GORD using validated questionnaires, consented and invited to receive simultaneous home sleep and oesophageal pH monitoring. Those with confirmed OSA and GORD (n=44) will be randomly allocated to receive either CPAP (n=22) or MAD therapy (n=22). Following successful titration and 3 weeks customisation period, participants will repeat the simultaneous sleep and oesophageal pH monitoring while wearing the device. The number of patients screened for recruitment, drop-out rates, patient feedback of the study protocol, costs of interventions and clinical information to inform a definitive study design will be investigated., Ethics and Dissemination: Health Research Authority approval has been obtained from the Nottingham 2 Research Ethics Committee, ref:22/EM/0157 and the trial has been registered on ISRCTN (https://doi.org/10.1186/ISRCTN16013232). Definitive findings about the feasibility of doing 24 hour pH oesophageal monitoring while doing a home sleep study will be disseminated via clinical and research networks facilitating valuable insights into the simultaneous management of both conditions., Trial Registration Number: ISRCTN Reg No: 16013232., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

Background: Hypoglossal nerve stimulation (HNS) for obstructive sleep apnoea (OSA) is a novel way to manage the condition. We hypothesised that in patients with OSA and limited adherence to continuous positive airway pressure (CPAP) therapy, domiciliary transcutaneous electrical stimulation (TESLA) would control sleep apnoea and provide health benefits., Methods: We undertook a single-centre, open-label, randomised, controlled phase III trial in patients with OSA (apnoea-hypopnoea-index [AHI] 5-35 h -1 ), a BMI of 18.5-32 kg∗m -2 , and a documented lack of adherence to CPAP therapy (<4 h∗night -1 ) at Guy's & St Thomas' NHS Foundation Trust (hospital), UK. Patients were randomly assigned (1:1) using minimisation (gender and OSA severity) to receive TESLA or usual care (CPAP) for at least 3 months; sleep study analysis was provided without knowledge of the assignment arm. The primary outcome was change in AHI at 3-months. The primary outcome and safety were analysed in the intention-to-treat population. Data are reported as median (interquartile range), unless otherwise explained. This trial is registered at ClinicalTrials.gov, NCT03160456., Findings: Between 6 June 2018 and 7 February 2023, 56 participants were enrolled and randomly assigned (29 patients in the intervention group and 27 in the usual care group). Patients were followed up for a median of 3.0 months (IQR 3.0; 10.0). The groups were similar in terms of age (55.8 (48.2; 66.0) vs 59.3 (47.8; 64.4) years), gender (male:female, 19:10 vs 18:9) and BMI (28.7 (26.4; 31.9) vs 28.4 (24.4; 31.9) kg∗m -2 ). The unadjusted group difference in the Δ AHI was -11.5 (95% CI -20.7; -2.3) h -1 (p = 0.016). Adjusted for the baseline value, the difference was Δ AHI -7.0 (-15.7; 1.8) h -1 (p = 0.12), in favour of the intervention. Minor adverse events were found in one of the participants who developed mild headaches related to the intervention., Interpretation: Domiciliary TESLA can be used safely and effectively in OSA patients with poor adherence to CPAP, with favourable impact on sleepiness and sleep fragmentation. Despite pandemic-related limitations of the amended protocol this trial provides the evidence that TESLA improves clinically meaningful outcomes over the observed follow up period, and the transcutaneous approach is likely to offer an affordable alternative for responders to electrical stimulation in clinical practice., Funding: British Lung Foundation, United Kingdom Clinical Research Collaboration-registered King's Clinical Trials Unit at King's Health Partners., Competing Interests: JS is the named inventor on a patent for an ‘apparatus for treatment of snoring and sleep apnoea’ (WO2016124739A1) that is owned by his employing organisations (Guy’s & St Thomas’ NHS Foundation Trust/King’s College London, UK). MIP holds a Consultancy contract with Phillips Respironics (CPAP devices). All other authors declare no competing interests., (© 2023 The Author(s).)