Publications by authors named "Joerg Steier"

87 Publications

Residual excessive daytime sleepiness in patients treated for obstructive sleep apnea: guidance for assessment, diagnosis, and management.

Postgrad Med 2021 Sep 22;133(7):772-783. Epub 2021 Jul 22.

HP2 Laboratory, Inserm U1042, Grenoble Alpes University, Research Department, Grenoble, France.

Excessive daytime sleepiness (EDS) affects approximately half of patients with obstructive sleep apnea (OSA) and can persist in some despite normalization of breathing, oxygenation, and sleep quality with primary OSA therapy, such as continuous positive airway pressure (CPAP). EDS is often overlooked and under discussed in the primary care setting and in the follow-up of CPAP-treated patients due to difficult assessment of such a multi-dimensional symptom. This review aims to provide suggestions for procedures that can be implemented into routine clinical practice to identify, evaluate, and manage EDS in patients treated for OSA, including how to appropriately use various self-report and objective assessments along the clinical pathway and options for pharmacotherapy. In addition, examples of when it is appropriate to refer a patient to a sleep specialist for evaluation are discussed.
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http://dx.doi.org/10.1080/00325481.2021.1948305DOI Listing
September 2021

A Novel Group Cognitive Behavioral Therapy Approach to Adult Non-rapid Eye Movement Parasomnias.

Front Psychiatry 2021 1;12:679272. Epub 2021 Jul 1.

Sleep Disorder Centre, Nuffield House, Guy's Hospital, London, United Kingdom.

Following the success of Cognitive Behavioral Therapy (CBT) for insomnia, there has been a growing recognition that similar treatment approaches might be equally beneficial for other major sleep disorders, including non-rapid eye movement (NREM) parasomnias. We have developed a novel, group-based, CBT-program for NREM parasomnias (CBT-NREMP), with the primary aim of reducing NREM parasomnia severity with relatively few treatment sessions. We investigated the effectiveness of CBT-NREMP in 46 retrospectively-identified patients, who completed five outpatient therapy sessions. The outcomes pre- and post- CBT-NREMP treatment on clinical measures of insomnia (Insomnia Severity Index), NREM parasomnias (Paris Arousal Disorders Severity Scale) and anxiety and depression (Hospital Anxiety and Depression Scale), were retrospectively collected and analyzed. In order to investigate the temporal stability of CBT-NREMP, we also assessed a subgroup of 8 patients during the 3 to 6 months follow-up period. CBT-NREMP led to a reduction in clinical measures of NREM parasomnia, insomnia, and anxiety and depression severities [pre- vs. post-CBT-NREMP scores: (Insomnia Severity Index) = 0.000054; (Paris Arousal Disorders Severity Scale) = 0.00032; (Hospital Anxiety and Depression Scale) = 0.037]. Improvements in clinical measures of NREM parasomnia and insomnia severities were similarly recorded for a subgroup of eight patients at follow-up, demonstrating that patients continued to improve post CBT-NREMP. Our findings suggest that group CBT-NREMP intervention is a safe, effective and promising treatment for NREM parasomnia, especially when precipitating and perpetuating factors are behaviorally and psychologically driven. Future randomized controlled trials are now required to robustly confirm these findings.
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http://dx.doi.org/10.3389/fpsyt.2021.679272DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8281294PMC
July 2021

The ANDANTE Project: A Worldwide Individual Data Meta-Analysis of the Effect of Sleep Apnea Treatment on Blood Pressure

Arch Bronconeumol (Engl Ed) 2021 May 10. Epub 2021 May 10.

Department of Cardiovascular, Neural and Metabolic Sciences, IRCCS Istituto Auxologico Italiano, Milan, Italy; Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy. Electronic address:

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http://dx.doi.org/10.1016/j.arbres.2021.05.002DOI Listing
May 2021

Identifying bronchoconstriction from the ratio of diaphragm EMG to tidal volume.

Respir Physiol Neurobiol 2021 09 18;291:103692. Epub 2021 May 18.

State Key Laboratory of Respiratory Disease, Guangzhou Medical University, Guangzhou, China; Faculty of Life Sciences and Medicine, King's College London School of Medicine, London, UK; Adelaide Institute for Sleep Health, College of Medicine and Public Health, Flinders University, Australia. Electronic address:

Background: A fall of ≥ 20 % in forced expiratory volume in the first second (FEV1) with a cumulative dose of histamine ≤ 7.8 μmol is considered to indicate bronchial hyperactivity, but no method exists for patients who cannot perform spirometry properly. Here we hypothesized that increases in respiratory central output measured by chest wall electromyography of the diaphragm (EMGdi-c) expressed as a function of tidal volume (EMGdi-c/VT) would have discriminative power to detect a 'positive' challenge test.

Methods: In a physiological study EMGdi was recorded from esophageal electrode (EMGdi-e) in 16 asthma patients and 16 healthy subjects during a histamine challenge test. In a second study, EMGdi from chest wall surface electrodes (EMGdi-c) was measured during a histamine challenge in 44 asthma patients and 51 healthy subjects. VT was recorded from a digital flowmeter during both studies.

Results: With histamine challenge test the change in EMGdi-e/VT in patients with asthma was significantly higher than that in healthy subjects (104.2 % ± 48.6 % vs 0.03 % ± 17.1 %, p < 0.001). Similarly there was a significant difference in the change of EMGdi-c/VT between patients with asthma and healthy subjects (90.5 % ± 75.5 % vs 2.4 % ± 21.7 %, p < 0.001). At the optimal cut-off point (29 % increase in EMGdi-c/VT), the area under the ROC curve (AUC) for detection of a positive test was 0.91 (p < 0.001) with sensitivity 86 % and specificity 92 %.

Conclusions: We conclude that EMGdi-c/VT may be used as an alternative for the assessment of bronchial hypersensitivity and airway reversibility to differentiate patients with asthma from healthy subjects.
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http://dx.doi.org/10.1016/j.resp.2021.103692DOI Listing
September 2021

Second intercostal space electromyography as a measure of neural respiratory drive: Clinical utility and validity.

Respir Physiol Neurobiol 2021 08 8;290:103683. Epub 2021 May 8.

Centre for Human & Applied Physiological Sciences, King's College London, London, UK. Electronic address:

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http://dx.doi.org/10.1016/j.resp.2021.103683DOI Listing
August 2021

Breathing Synchronised Hypoglossal Nerve Stimulation with Inspire for Untreated Severe Obstructive Sleep Apnoea/Hypopnoea Syndrome: A Simulated Cost-Utility Analysis from a National Health Service Perspective.

Pharmacoecon Open 2021 Sep 28;5(3):475-489. Epub 2021 Apr 28.

MedTech Economics, 14 Marnhull Rise, Winchester, SO22 5FH, UK.

Background: Hypoglossal nerve stimulation (HNS) with Inspire is a novel treatment indicated for moderate or severe obstructive sleep apnoea/hypopnoea syndrome (OSAHS), intolerant to or unable to be treated with continuous positive airway pressure (CPAP).

Objective: The aim of this study was to assess the cost effectiveness of treating moderate or severe OSAHS, in patients intolerant to CPAP, with HNS, compared with standard care, from a National Health Service (NHS) perspective.

Methods: A cohort state transition model was developed to compare HNS with Inspire with no treatment in UK adult patients with moderate or severe OSAHS who have previously tried and have not responded to CPAP therapy. Published literature was applied in the model to estimate incremental cost-effectiveness ratios (ICERs; 2019 Great British pounds per quality-adjusted life-year [QALY] gained), from an NHS and personal social services (PSS) perspective, over a cohort's lifetime.

Results: The model base-case predicts that patients undergoing HNS will incur lifetime costs of £65,026 compared with £36,727 among untreated patients. The HNS cohort would gain 12.72 QALYs compared with 11.15 QALYs in the no-treatment arm. The ICER of treating severe OSAHS with HNS is therefore estimated to be £17,989 per QALYs gained. Probabilistic sensitivity analysis found that at a threshold of £30,000/QALY, HNS has a 69% probability of being cost effective. Limitations of the model include uncertainty around the utility data that were not sourced directly from HNS clinical trials. There is further uncertainty in the relationship between change in the Apnoea-Hypopnoea Index (AHI) and reduction in ischaemic heart disease and stroke because of difficulty capturing the reduction in risk over a long time horizon in studies.

Conclusions: Over a patient's lifetime, HNS with Inspire is expected to be cost effective when compared with no treatment in patients with severe OSAHS who have tried and have not responded to CPAP, from an NHS perspective.
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http://dx.doi.org/10.1007/s41669-021-00266-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8333158PMC
September 2021

Parasternal electromyography as a surrogate measure of neural respiratory drive: Practical application and validity of surface and implanted fine wire methods.

Respir Physiol Neurobiol 2021 05 24;287:103602. Epub 2021 Jan 24.

Lane Fox Clinical Respiratory Physiology Research Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK; Centre for Human & Applied Physiological Sciences, King's College London, London, UK. Electronic address:

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http://dx.doi.org/10.1016/j.resp.2020.103602DOI Listing
May 2021

Impact of the novel coronavirus (COVID-19) pandemic on sleep.

J Thorac Dis 2020 Oct;12(Suppl 2):S163-S175

British Sleep Society, Lichfield, UK.

Background: The COVID-19 pandemic has led to significant changes in daily routines and lifestyle worldwide and mental health issues have emerged as a consequence. We aimed to assess the presence of sleep disturbances during the lockdown in the general population.

Methods: Cross-sectional, online survey-based study on adults living through the COVID-19 pandemic. The questionnaire included demographics and specific questions assessing the impact of the pandemic/lockdown on sleep, daytime functioning and mental health in the general population. Identification of sleep pattern changes and specific sleep-related symptoms was the primary outcome, and secondary outcomes involved identifying sleep disturbances for predefined cohorts (participants reporting impact on mental health, self-isolation, keyworker status, suspected COVID-19 or ongoing COVID-19 symptoms).

Results: In total, 843 participants were included in the analysis. The majority were female (67.4%), middle aged [52 years (40-63 years)], white (92.2%) and overweight to obese [BMI 29.4 kg/m (24.1-35.5 kg/m)]; 69.4% reported a change in their sleep pattern, less than half (44.7%) had refreshing sleep, and 45.6% were sleepier than before the lockdown; 33.9% had to self-isolate, 65.2% reported an impact on their mental health and 25.9% were drinking more alcohol during the lockdown. More frequently reported observations specific to sleep were 'disrupted sleep' (42.3%), 'falling asleep unintentionally' (35.2%), 'difficulties falling'/'staying asleep' (30.9% and 30.8%, respectively) and 'later bedtimes' (30.0%). Respondents with suspected COVID-19 had more nightmares and abnormal sleep rhythms. An impact on mental health was strongly associated with sleep-related alterations.

Conclusions: Sleep disturbances have affected a substantial proportion of the general population during the COVID-19 pandemic lockdown. These are significantly associated with a self-assessed impact on mental health, but may also be related to suspected COVID-19 status, changes in habits and self-isolation.
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http://dx.doi.org/10.21037/jtd-cus-2020-015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7642637PMC
October 2020

The value of a post-polio syndrome self-management programme.

J Thorac Dis 2020 Oct;12(Suppl 2):S153-S162

Guy's and St Thomas' NHS Foundation Trust, London, UK.

Background: Post-polio syndrome is characterised by symptoms of fatigue, pain and new-onset neuromuscular weakness, and emerges decades after the initial poliovirus infection. We sought to evaluate the only post-polio syndrome specific self-management programme in the United Kingdom.

Methods: This was a retrospective study of patients who had completed a residential self-management programme led by a multi-disciplinary clinical team. Following a confirmed diagnosis of post-polio syndrome by rehabilitation and neurology specialists, patients were offered to participate in the programme. Although group-based, patients also received individually tailored support on physical exercise and fatigue management. Physical effects, physical function, psychosocial well-being measures were assessed at baseline and 6 months follow-up. Knowledge was tested at baseline and immediately following the programme. Statistical comparisons were made using paired t-test and Wilcoxon signed rank test according to the data distribution.

Results: Over a period of 17 years, 214 participants (median age 61.3 years old, 63% female) attended 31 programmes. At 6 months the following post-polio syndrome specific symptoms improved significantly: fatigue, as measured by the Multidimensional Assessment of Fatigue scale [37.6 (7.1) . 34.2 (9.3), P=0.005]; and pain [15.0 (6.1) . 13.1 (6.7), P=0.001], atrophy [10.0 (8.0-12.0) . 9.0 (7.0-11.0), P=0.002] and bulbar symptoms [3.0 (1.0-5.0) . 2.0 (0-4.0), P=0.003] as measured by the Index of Post-polio Sequelae scale. Knowledge related to post-polio syndrome also significantly increased [14.0 (11.0-16.0) . 17.0 (16.0-19.0), P=0.001]. Participants were able to walk at a faster speed over 10 meters [0.77 (0.59-1.00) . 0.83 (0.67-1.10) m/s, P=0.003] and walked longer distances during the 2-minute walk test [76.9 (31.7) . 82.0 (38.4) m, P=0.029]. Depression and anxiety scores did not change over time [PHQ-9, 2.0 (0.3-10.8) . 2.0 (0.3-6.8), P=0.450; GAD-7, 2.0 (0-7.0) . 1.0 (0-3.0), P=0.460] nor was there change in self-reported quality of life {60 [50-70] . 60 [55-70], P=0.200}.

Conclusions: This study suggests that a post-polio syndrome self-management programme led to improvement in symptoms, knowledge and walking speed, but not quality of life. Anxiety and depression scores remained low.
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http://dx.doi.org/10.21037/jtd-cus-2020-009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7642628PMC
October 2020

Ultrasound assessment of upper airway dilator muscle contraction during transcutaneous electrical stimulation in patients with obstructive sleep apnoea.

J Thorac Dis 2020 Oct;12(Suppl 2):S139-S152

Lane Fox Unit/Sleep Disorders Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK.

Background: Electrical current can be used to stimulate upper airway dilator muscles to treat obstructive sleep apnoea (OSA). Ultrasound devices are widely available and may be used to detect contraction of the upper airway dilator muscles assessing the functionality of electrical stimulation (ES) used for this treatment.

Methods: In a physiological sub-study of a randomised controlled trial, patients with OSA underwent ultrasound examination to assess contraction of the upper airway dilator muscles in response to transcutaneous ES. Ultrasound scans were scored according to the picture quality (poor = '0', acceptable = '1' and good = '2'). Tongue base thickness was assessed in mid-sagittal and coronal planes with (D2, A2) and without ES (D1, A1), while awake and seated. The primary outcome was to determine the increase in tongue thickness during ES in both views (D2 - D1 = ΔD), as well as any increase in the cross-sectional area (CSA) in the coronal view (A2 - A1 = ΔA). Data were presented as mean and standard deviation (SD).

Results: Fourteen patients [eight male, age 57.5 (9.8) years, body mass index (BMI) 29.5 (2.8) kg/m] with OSA [Apnea-Hypopnea Index (AHI) 19.5 (10.6) × hour] were studied. Quality of the ultrasound scans was acceptable or good with 1.5 (0.5) points. In the mid-sagittal plane, ΔD was +0.17 (0.07) cm in midline and +0.21 (0.09) cm in the widest diameter, a percentual change of 12.2% (4%) and 12.8% (5.2%) (P<0.001, respectively). In the coronal plane, ΔD was +0.17 (0.04) cm, an increase of 12.3% (4.6%) (P<0.001, respectively), ΔA in the CSA increased by +18.9% (3.0%) with stimulation (P<0.001). There was a negative correlation between age and ΔA (r= -0.6, P=0.03), but no significant associations were found with gender, BMI, neck circumference, Epworth Sleepiness Scale (ESS), AHI, skin and subcutaneous tissue in the submental area.

Conclusions: Ultrasound can visualise upper airway dilator muscle contraction during transcutaneous ES in awake patients with OSA. Contraction is best detected in the CSA of the tongue base in the coronal plane.
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http://dx.doi.org/10.21037/jtd-cus-2020-001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7642638PMC
October 2020

Long-term adherence to home mechanical ventilation: a 10-year retrospective, single-centre cohort study.

J Thorac Dis 2020 Oct;12(Suppl 2):S120-S128

Faculty of Life Sciences and Medicine, King's College London, London, UK.

Background: Sleep-disordered breathing (SBD) can be associated with hypercapnic respiratory failure (HRF). Home Mechanical Ventilation (HMV) is the preferred long-term treatment for patients with chronic HRF. We reviewed the database of a large tertiary referral centre for HMV to study the long-term adherence to HMV in chronic hypercapnic patients.

Methods: Data on adherence and characteristics of patients who received HMV for the treatment of SDB were collected over a decade using electronic patient records. The primary outcome parameter in this study was annual non-adherence rate (patients with HMV usage of <4 hours/night in the service divided by the number of all new patients of the same year), secondary outcomes were patients' characteristics and reasons for low adherence. HMV adherence clinics were established to improve uptake.

Results: Two thousand and two hundred twenty-eight patients with HRF were under active follow-up on HMV at the end of the recording period. In contrast, a total of 1,900 patients had their HMV contracts terminated over the course of a decade (due to non-adherence, transfer to other services or death). Out of those, 222 patients {62 [52-72] years, body-mass index, BMI 40 [35-43] kg/m, 58.1% male, Epworth Sleepiness Scale, ESS 9 [4-15] points, 4% oxygen desaturation index, 4%ODI 32 [20-71] × hour, TcCO 6.6 [6.0-7.2] kPa} met the non-adherence criteria (nocturnal usage 0-4 hours). The annual non-adherence rate was 25.5% of all new setups in 2010, and declined to 3.4% in 2019 (relative reduction of 86%, P<0.001). Patients with Obstructive Sleep Apnoea/Obesity Hypoventilation Syndrome (58.2%), Neuromuscular Diseases (NMD) (26.8%) and COPD (13.6%) accounted for most cases of this non-adherent cohort. The vast majority of the patients (96.1%) were established on full-face masks. In 23.4% of patients, substantial weight loss (>10%) was the most common reason for low adherence; general displeasure (21.3%), uncontrolled symptoms (12.8%), claustrophobia (6.7%), mood (4.8%) and mask intolerance (4.3%) caused problems as well.

Conclusions: Non-adherence to HMV in patients with chronic HRF can affect significant proportions of patients. However, the non-adherent rate substantially decreases when individual treatment solutions are offered in multi-disciplinary clinics.
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http://dx.doi.org/10.21037/jtd-cus-2020-003DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7642640PMC
October 2020

Apnoea-hypopnoea-index comparing the 2007 and 2012 American Academy of Sleep Medicine criteria in chronic obstructive pulmonary disease/obstructive sleep apnoea overlap syndrome.

J Thorac Dis 2020 Oct;12(Suppl 2):S112-S119

Lane Fox Unit/Sleep Disorders Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK.

Background: In 2007 and 2012, the American Academy of Sleep Medicine (AASM) updated their scoring criteria for nocturnal respiratory events. We hypothesised that this could have led to changes in the apnoea-hypopnoea index (AHI) of patients with chronic obstructive pulmonary disease (COPD)/obstructive sleep apnoea (OSA) overlap syndrome.

Methods: In a retrospective study, polysomnographic (PSG) recordings of 34 patients with COPD/OSA overlap syndrome were independently analysed using the AASM criteria from 2007 (AASM) and 2012 (AASM). The primary outcome was the difference in AHI, the secondary outcomes were frequency of hypopnoeas, diagnosis of overlap syndrome and differences between the AASM 2007 recommended (AASM) and altered (AASM) classifications. Data are presented as mean (standard deviation) if normally distributed, and as median (interquartile range) if non-normally distributed.

Results: The PSGs of 34 elderly [aged 67 (7.0) years] and predominantly male (m:f, 31:3) patients with COPD [FEV%pred 48.4% (19.6%)] were analysed. The AHI using AASM criteria was 5.9 (2.0, 15.1) events/hour 20.4 (11.5, 28.0) events/hour using the 2012 criteria (P<0.001); with the AASM criteria, the AHI was 15.0 (9.3, 26.3) events/hour (P<0.001). Using the 2012 classification, the number of scored hypopnoeas increased by +48% compared to the AASM criteria (P<0.001), 92% of these events were associated with arousal. Although statistically non-significant, using the AASM classification, 12% of our cohort would not have been diagnosed with COPD/OSA overlap syndrome (P=0.114), this was also the case for 47% of the cohort when the AASM classification was used (P<0.01).

Conclusions: The use of the AASM scoring rules results in a significantly higher AHI compared to the AASM criteria in patients with COPD/OSA overlap syndrome, mostly due to an increased number of arousal-associated hypopnoeas. These observations are important for the definition of the COPD/OSA overlap syndrome.
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http://dx.doi.org/10.21037/jtd-cus-2020-008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7642634PMC
October 2020

5 Clinical Update Sleep: "a virtual briefing".

Authors:
Joerg Steier

J Thorac Dis 2020 Oct;12(Suppl 2):S110-S111

Course Director, Professor of Respiratory & Sleep Medicine, Guy's & St. Thomas NHS Foundation Trust, King's College London, London, UK. (Email:

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http://dx.doi.org/10.21037/jtd-cus-2020-prefaceDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7642635PMC
October 2020

British Sleep Society: the COVID-19 pandemic response.

J Thorac Dis 2020 Aug;12(8):4469-4475

British Sleep Society, Lichfield, UK.

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http://dx.doi.org/10.21037/jtd-2020-059DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7475546PMC
August 2020

Long-term survival following initiation of home non-invasive ventilation: a European study.

Thorax 2020 11 7;75(11):965-973. Epub 2020 Sep 7.

Lane Fox Clinical Respiratory Physiology Research Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK.

Introduction: Although home non-invasive ventilation (NIV) is increasingly used to manage patients with chronic ventilatory failure, there are limited data on the long-term outcome of these patients. Our aim was to report on home NIV populations and the long-term outcome from two European centres.

Methods: Cohort analysis including all patients established on home NIV from two European centres between 2008 and 2014.

Results: Home NIV was initiated in 1746 patients to treat chronic ventilatory failure caused by (1) obesity hypoventilation syndrome±obstructive sleep apnoea (OHS±OSA) (29.5%); (2) neuromuscular disease (NMD) (22.7%); and (3) obstructive airway diseases (OAD) (19.1%). Overall cohort median survival following NIV initiation was 6.6 years. Median survival varied by underlying aetiology of respiratory failure: rapidly progressive NMD 1.1 years, OAD 2.7 years, OHS±OSA >7 years and slowly progressive NMD >7 years. Multivariate analysis demonstrated higher mortality in patients with rapidly progressive NMD (HR 4.78, 95% CI 3.38 to 6.75), COPD (HR 2.25, 95% CI 1.64 to 3.10), age >60 years at initiation of home NIV (HR 2.41, 95% CI 1.92 to 3.02) and NIV initiation following an acute admission (HR 1.38, 95% CI 1.13 to 1.68). Factors associated with lower mortality were NIV adherence >4 hours per day (HR 0.64, 95% CI 0.51 to 0.79), OSA (HR 0.51, 95% CI 0.31 to 0.84) and female gender (HR 0.79, 95% CI 0.65 to 0.96).

Conclusion: The mortality rate following initiation of home NIV is high but varies significantly according to underlying aetiology of respiratory failure. In patients with chronic respiratory failure, initiation of home NIV following an acute admission and low levels of NIV adherence are poor prognostic features and may be amenable to intervention.
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http://dx.doi.org/10.1136/thoraxjnl-2019-214204DOI Listing
November 2020

The load and capacity model of healthcare delivery: considerations for the crisis management of the COVID-19 pandemic.

J Thorac Dis 2020 Jun;12(6):3022-3030

CHAPS, Faculty of Life Sciences and Medicine, King's College London, UK.

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http://dx.doi.org/10.21037/jtd-2020-054DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7330742PMC
June 2020

Electrical stimulation as a therapeutic approach in obstructive sleep apnea - a meta-analysis.

Sleep Breath 2021 Mar 9;25(1):207-218. Epub 2020 May 9.

Lane Fox Respiratory Unit and Sleep Disorders Centre, Guy's and St Thomas' Hospital NHS Foundation Trust, London, SE1 7EH, UK.

Purpose: Electrical stimulation of the upper airway dilator muscles is an emerging treatment for obstructive sleep apnea (OSA). Invasive hypoglossal nerve stimulation (HNS) has been accepted as treatment alternative to continuous positive airway pressure (CPAP) for selected patients, while transcutaneous electrical stimulation (TES) of the upper airway is being investigated as non-invasive alternative.

Methods: A meta-analysis (CRD42017074674) on the effects of both HNS and TES on the apnea-hypopnea index (AHI) and the Epworth Sleepiness Scale (ESS) in OSA was conducted including published evidence up to May 2018. Random-effects models were used. Heterogeneity and between-study variance were assessed by I and τ, respectively.

Results: Of 41 identified clinical trials, 20 interventional trials (n = 895) could be pooled in a meta-analysis (15 HNS [n = 808], 5 TES [n = 87]). Middle-aged (mean ± SD 56.9 ± 5.5 years) and overweight (body mass index 29.1 ± 1.5 kg/m) patients with severe OSA (AHI 37.5 ± 7.0/h) were followed-up for 6.9 ± 4.0 months (HNS) and 0.2 ± 0.4 months (TES), respectively. The AHI improved by - 24.9 h [95%CI - 28.5, - 21.2] in HNS (χ 79%, I 82%) and by - 16.5 h [95%CI - 25.1, - 7.8] in TES (χ 7%, I 43%; both p < 0.001). The ESS was reduced by - 5.0 (95%CI - 5.9, - 4.1) (p < 0.001).

Conclusion: Both invasive and transcutaneous electrical stimulation reduce OSA severity by a clinically relevant margin. HNS results in a clinically relevant improvement of symptoms. While HNS represents an invasive treatment for selected patients with moderate to severe OSA, TES should be further investigated as potential non-invasive approach for OSA.
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http://dx.doi.org/10.1007/s11325-020-02069-2DOI Listing
March 2021

Qualitative Phenotyping of Obstructive Sleep Apnea and Its Clinical Usefulness for the Sleep Specialist.

Int J Environ Res Public Health 2020 03 20;17(6). Epub 2020 Mar 20.

Pulmonary Operative Unit, Department of Thoracic Diseases, Morgagni-Pierantoni Hospital, Romagna Health Company, 47121 Forlì, Italy.

Introduction: The anatomical collapsibility of the upper airway, neuromuscular tone and function, sleep-wake and ventilatory control instability, and the arousal threshold all interact and contribute to certain pathophysiologic features that characterize different types of obstructive sleep apnea (OSA). A model of qualitative phenotypizationallowsus to characterize the different pathophysiological traits in OSA patients.

Methods: A narrative review was performed, to analyze the available literature evidence, with the purpose of generating a model of qualitative phenotypization to characterize pathophysiological traits in patients with OSA.

Results: 96 out of 3829 abstracts were selected for full-text review. Qualitative phenotyping model of OSA:Data concerning the OSA qualitative pathophysiological traits' measurement can be deducted by means of clinical PSG, grade of OSA severity, and therapeutic level of Continuous Positive Airway Pressure (CPAP) and are reported in the text. This approach would allow qualitative phenotyping with widely accessible methodology in a routine clinical scenario and is of particular interest for the sleep specialist, surgical treatment decision-making, and customized OSA multimodality treatment.
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http://dx.doi.org/10.3390/ijerph17062058DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7143772PMC
March 2020

Obstructive sleep apnoea treatment and blood pressure: which phenotypes predict a response? A systematic review and meta-analysis.

Eur Respir J 2020 05 7;55(5). Epub 2020 May 7.

Section of General Medicine and Hypertension, Dept of Medicine, University of Verona, Verona, Italy

The treatment for obstructive sleep apnoea (OSA) with continuous positive airway pressure (CPAP) or mandibular advancement devices (MADs) is associated with blood pressure (BP) reduction; however, the overall effect is modest. The aim of this systematic review and meta-analysis of randomised controlled trials (RCTs) comparing the effect of such treatments on BP was to identify subgroups of patients who respond best to treatment.The article search was performed in three different databases with specific search terms and selection criteria. From 2289 articles, we included 68 RCTs that compared CPAP or MADs with either passive or active treatment. When all the studies were pooled together, CPAP and MADs were associated with a mean BP reduction of -2.09 (95% CI -2.78- -1.40) mmHg for systolic BP and -1.92 (95% CI -2.40- -1.43) mmHg for diastolic BP and -1.27 (95% CI -2.34- -0.20) mmHg for systolic BP and -1.11 (95% CI -1.82- -0.41) mmHg for diastolic BP, respectively. The subgroups of patients who showed a greater response were those aged <60 years (systolic BP -2.93 mmHg), with uncontrolled BP at baseline (systolic BP -4.14 mmHg) and with severe oxygen desaturations (minimum arterial oxygen saturation measured by pulse oximetry <77%) at baseline (24-h systolic BP -7.57 mmHg).Although this meta-analysis shows that the expected reduction of BP by CPAP/MADs is modest, it identifies specific characteristics that may predict a pronounced benefit from CPAP in terms of BP control. These findings should be interpreted with caution; however, they are particularly important in identifying potential phenotypes associated with BP reduction in patients treated for OSA.
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http://dx.doi.org/10.1183/13993003.01945-2019DOI Listing
May 2020

Time-to-death in chronic respiratory failure on home mechanical ventilation: A cohort study.

Respir Med 2020 02 13;162:105877. Epub 2020 Jan 13.

Lane Fox Respiratory Unit and Lane Fox Clinical Respiratory Physiology Research Centre, Guy's and St Thomas' Hospital NHS Foundation Trust, SE1 7EH, London, UK; Faculty of Life Sciences and Medicine, King's College London, WC2R 2LS, London, UK.

Background And Objective: Home mechanical ventilation (HMV) is used in heterogeneous conditions underlying chronic hypercapnic respiratory failure, but there are sparse data on long-term clinical outcomes. The aim was to systematically analyse the time and the circumstances of death on HMV.

Methods: All-cause mortality data of HMV patients were prospectively collected between 2008 and 2018 in a large tertiary centre. Data were categorised into diagnostic groups including neuromuscular disease (NMD), chest wall disease (CWD), chronic obstructive pulmonary disease (COPD), obesity hypoventilation syndrome (OHS), overlap syndrome of COPD and OSA (overlap) and other group. The primary outcome was time-to-death from initiation of HMV.

Results: 1210 deaths were recorded over a 10-year period. Median time-to-death was 19.5 [6-55] months and differed between groups (Kruskal Wallis p < 0.001). CWD (98.5 [23.5-120] months) and slowly progressive NMD (64.5 [28-120] months) had the longest time-to-death on HMV, while OHS (33 [13-75] months) and overlap syndrome (30.5 [14.5-68.5] months) had a longer median time-to-death than COPD (19.5 [7-42.5] months) and motor neurone disease (7 [3-14] months). Daily adherence to HMV of greater than 4 h/night was associated with better outcomes (10 [3-24] vs. 30 [10-76] months; p < 0.001). 43% with confirmed location of death died outside the hospital.

Conclusions: The time-to-death on home mechanical ventilation varies widely across disease groups with chronic respiratory failure and seems to be associated with daily usage time.

Trial Registration: researchregistry.com UIN: researchregistry4122.
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http://dx.doi.org/10.1016/j.rmed.2020.105877DOI Listing
February 2020

Electrical stimulation in obstructive sleep apnoea: the less invasive the better?

Eur Respir J 2020 02 6;55(2). Epub 2020 Feb 6.

Centre of Human and Applied Physiology (CHAPS), King's College London, London, UK

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http://dx.doi.org/10.1183/13993003.02013-2019DOI Listing
February 2020

Absence of dynamic hyperinflation during exhaustive exercise in severe COPD reflects submaximal IC maneuvers rather than a nonhyperinflator phenotype.

J Appl Physiol (1985) 2020 03 16;128(3):586-595. Epub 2020 Jan 16.

Respiratory Muscle Laboratory, Heart and Lung Institute, Imperial College and the Royal Brompton Hospital, London, United Kingdom.

Approximately 20% of chronic obstructive pulmonary disease (COPD) patients have been considered to have a "nonhyperinflator phenotype." However, this judgment depends on patients making a fully maximal inspiratory capacity (IC) maneuver at rest, since the IC during exercise is compared with this baseline measurement. We hypothesized that IC maneuvers at rest are sometimes submaximal and tested this hypothesis by measuring IC and associated neural respiratory drive at rest and during inhalation of CO and exercise in patients with COPD. Twenty-six COPD patients [age 66 ± 6 yr, mean forced expiratory volume in 1 s (FEV) 40 ± 11% predicted] and 39 healthy subjects (age 39 ± 14 yr, FEV 98 ± 12% predicted) were studied. IC and the diaphragm electromyogram (EMG) associated with it (EMG-IC) and forced inspiratory vital capacity (FIVC) and its corresponding EMG (EMG-FIVC) were measured during inhalation of 8% CO (8% CO-92% O) and room air. Incremental exhaustive cycle ergometer exercise was also performed in both patients with COPD and healthy subjects. IC, EMG-IC, FIVC, and EMG-FIVC during breathing 8% CO were significantly greater than those during breathing room air in both patients with COPD and healthy subjects (all < 0.001). EMG-IC in patients with COPD constantly increased during exercise from 145 ± 40 µV at rest to 185 ± 52 µV at the end of exercise but change in IC was variable. Neural respiratory drive and its relevant IC increased during hypercapnia. Exercise-related hypercapnia in patients with COPD raises neural respiratory drives, which compensate for IC reduction, leading to underestimation of dynamic hyperinflation measured by IC at rest breathing room air. Inspiratory capacity measured during hypercapnia is higher than that during eucapnia. Thus total lung capacity is not always be achieved by a standard inspiratory capacity maneuver, leading to risk of underestimation of dynamic hyperinflation in patients with severe chronic obstructive pulmonary disease after exhaustive exercise.
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http://dx.doi.org/10.1152/japplphysiol.00695.2018DOI Listing
March 2020

Effect of Treatment of Central Sleep Apnea/Cheyne-Stokes Respiration on Left Ventricular Ejection Fraction in Heart Failure: A Network Meta-Analysis.

J Clin Sleep Med 2019 12 30;15(12):1817-1825. Epub 2019 Oct 30.

Department of Pulmonology and Sleep Disorders Centre, University Hospital of Zurich, Zurich, Switzerland.

Study Objectives: Patients who have experienced heart failure with central sleep apnea/Cheyne-Stokes respiration (CSA/CSR) have an impaired prognosis. Continuous positive airway pressure (CPAP) and adaptive servoventilation (ASV) as well as nocturnal oxygen (O₂) are proposed treatment modalities of CSA/CSR. The goal of the study is to assess whether and how different treatments of CSA/CSR affect cardiac function.

Methods: Databases were searched up to December 2017 for randomized controlled trials (RCTs) comparing the effect of any combination of CPAP, ASV, O₂ or an inactive control on left ventricular ejection fraction (LVEF) in patients with heart failure and CSA/CSR. A systematic review and network meta-analysis using multivariate random-effects meta-regression were performed.

Results: Twenty-four RCTs (1,289 patients) were included in the systematic review and data of 16 RCTs (951 patients; apnea-hypopnea-index 38 ± 3/h, LVEF 29 ± 3%) could be pooled in a network meta-analysis. Compared to an inactive control, both CPAP and ASV significantly improved LVEF by 4.4% (95% confidence interval 0.3-8.5%, P = 0.036) and 3.8% (95% confidence interval 0.6-7.0%, P = 0.025), respectively, whereas O₂ had no effect on LVEF (P = 0.35). There was no difference in treatment effects on LVEF between CPAP and ASV (P = 0.76). The treatment effect of positive pressure ventilation was larger when baseline LVEF was lower in systolic heart failure.

Conclusions: CPAP and ASV are effective in improving LVEF in patients with heart failure and CSA/CSR to a clinically relevant amount, whereas nocturnal O₂ is not. There is no difference between CPAP and ASV in the comparative beneficial effect on cardiac function.
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http://dx.doi.org/10.5664/jcsm.8092DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7099193PMC
December 2019

Corrigendum to "NREM parasomnias: a treatment approach based upon a retrospective case series of 512 patients" [Sleep Med 53 (2019) 181-188].

Sleep Med 2020 Jan 21;65:186. Epub 2019 Oct 21.

Sleep Disorders Centre, Guy's Hospital, Great Maze Pond, London, SE1 9RT, United Kingdom; Sleep and Brain Plasticity Centre, Department of Neuroimaging, IoPPN, King's College London, United Kingdom; Department of Basic and Clinical Neurosciences, IoPPN, King's College London, United Kingdom. Electronic address:

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http://dx.doi.org/10.1016/j.sleep.2019.07.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7184957PMC
January 2020

BPAP is an effective second-line therapy for obese patients with OSA failing regular CPAP: A prospective observational cohort study.

Respirology 2020 04 12;25(4):443-448. Epub 2019 Aug 12.

Faculty of Life Sciences and Medicine, Centre for Human and Applied Physiological Science (CHAPS), King's College London, London, UK.

Background And Objective: Continuous positive airway pressure (CPAP) is the most common treatment for obstructive sleep apnoea (OSA), but many patients fail long-term therapy. Bilevel positive airway pressure (BPAP) is a potential alternative. We hypothesized that BPAP could improve treatment adherence and outcomes in patients who cannot tolerate CPAP.

Methods: Patients with OSA who failed CPAP (usage < 4 h/day) and were referred to a tertiary sleep centre between 2014 and 2017 for BPAP were included. Age, gender, body mass index (BMI), co-morbidities, CPAP use and reasons for failure, Epworth Sleepiness Scale (ESS), sleep study data, spirometry data and average maximum nightly compliance were recorded.

Results: A total of 52 patients with OSA requiring CPAP > 15 cm H O (71% male, age: 58 (15) years, BMI: 42.6 (10.1) kg/m , apnoea-hypopnoea index (AHI): 51.1 (30.4)/h) were studied; 62% had respiratory co-morbidities affecting nocturnal breathing including obesity hypoventilation syndrome and COPD; 25% had neuromuscular conditions; and 17% had cardiovascular disease. CPAP was used for 199 (106-477) days prior to referral for BPAP. Reasons for CPAP failure were intolerant pressures (23%), uncontrolled symptoms (23%), mask problems (21%), adverse effects (13%), claustrophobia (8%), co-morbidities (8%) and other issues (4%). Lower expiratory positive airway pressures were needed with BPAP compared to CPAP (10 (8-12) vs 16.8 (15.7-19.2) cm H O, P = 0.001); patients achieved better adherence to BPAP (7.0 (4.0-8.5) vs 2.5 (1.6-6.7) h/night, P = 0.028) and better symptom control (ESS: 4.0 (1.0-7.0) vs 10.0 (6.0-17.0) points, P = 0.039).

Conclusion: In patients with moderate-severe OSA who fail CPAP therapy due to low adherence, BPAP is well tolerated and achieves sufficient control of sleep-disordered breathing and its symptoms.
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http://dx.doi.org/10.1111/resp.13674DOI Listing
April 2020

Domiciliary use of transcutaneous electrical stimulation for patients with obstructive sleep apnoea: a conceptual framework for the TESLA home programme.

J Thorac Dis 2019 May;11(5):2153-2164

Lane Fox Unit/Sleep Disorders Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK.

Obstructive sleep apnoea (OSA) is a global health problem of increasing prevalence. Effective treatments are available with continuous positive airway pressure (CPAP) therapy and mandibular advancement devices (MAD). However, there is limited long-term adherence to therapy, as CPAP and MAD require permanent usage to avoid recurrence of the symptoms and adverse ill health. Alternative treatments would aid in the treatment cascade to manage OSA effectively whenever standard therapy has been trialled and failed. Hypoglossal nerve stimulation (HNS), an invasive approach to stimulate the pharyngeal dilator muscles of the upper airway during sleep, has been approved for the treatment of OSA by several healthcare systems in recent years. In parallel to the development of HNS, a non-invasive approach has been developed to deliver electrical stimulation. Transcutaneous electrical stimulation in obstructive sleep apnoea (TESLA) uses non-invasive electrical stimulation to increase neuromuscular tone of the upper airway dilator muscles of patients with OSA during sleep. Data from previous feasibility studies and randomised controlled trials have helped to identify a subgroup of patients who are "responders" to this treatment. However, further investigations are required to assess usability, functionality and task accomplishment of this novel treatment. Consideration of these factors in the study design of future clinical trials will strengthen research methodology and protocols, improve patient related outcome measures and assessments, to optimise this emerging therapeutical option. In this review, we will introduce a conceptual framework for the TESLA home programme highlighting qualitative aspects and outcomes.
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http://dx.doi.org/10.21037/jtd.2019.05.04DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6588784PMC
May 2019

Self-reported sleepiness in the context of fitness-to-drive.

Sleep Breath 2019 Dec 19;23(4):1227-1232. Epub 2019 Mar 19.

Lane Fox Respiratory Unit / Sleep Disorders Centre, Guy's and St Thomas' NHS Foundation Trust, Westminster Bridge Road, London, SE1 7EH, UK.

Background: Excessive daytime sleepiness (EDS) is a contributing factor to road traffic accidents. It is commonly assessed using self-administered questionnaires. These assessments are important information when discussing with the Driver and Vehicle Licensing Agency (DVLA) about fitness-to-drive. We hypothesised that patients may be confounded in their assessments after being informed about these potential implications.

Patients And Methods: This was a prospective single-centre study. Patients attending clinics for sleep-disordered breathing were asked to fill in the Epworth Sleepiness Scale (ESS) and the Stanford Sleepiness Scale (SSS). Following their consultation, patients were informed about EDS in the context of driving and that the DVLA might request information based on their self-assessed sleepiness. They were then asked to complete the same questionnaires again. Parameters recorded included age, gender, body mass index (BMI), driving licence holder, and collar size. An ESS score above 10 points was defined as EDS.

Results: One hundred twenty-two subjects were studied (age 59.4 years (15.2); 72 males; BMI 32.1 kg/m (8.3), driving licence held for 25.2 years (20.6) (n = 94); collar size 42.7 cm (5.0)). There was no difference in the ESS [8 (8) vs 8 (8) points; p = 0.289] or the SSS [2 (2) vs 2 (2) points; p = 0.320] between the two occasions, although seven patients (5.7%) changed their scores from "sleepy" to "non-sleepy" and four patients (3.3%) from "non-sleepy" to "sleepy".

Conclusion: Providing patients with information about the risk of driving in the context of sleepiness does not significantly change how they score their symptoms using self-administered questionnaires; only about 9.0% of the patients had inconsistent results.
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http://dx.doi.org/10.1007/s11325-019-01810-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6868045PMC
December 2019

Noninvasive ventilation: education and training. A narrative analysis and an international consensus document.

Adv Respir Med 2019 4;87(1):36-45. Epub 2019 Mar 4.

Respiratory Unit, AO Ospedali dei Colli Naples PO, Monaldi, Italy.

Noninvasive ventilation (NIV) is an increasingly used method of respiratory support. The use of NIV is expanding over the time and if properly applied, it can save patients' lives and improve long-term prognosis. However, both knowledge and skills of its proper use as life support are paramount. This systematic review aimed to assess the importance of NIV education and training. Literature search was conducted (MEDLINE: 1990 to June, 2018) to identify randomized controlled studies and systematic reviews with the results analyzed by a team of experts across the world through e-mail based communications. Clinical trials examining the impact of education and training in NIV as the primary objective was not found. A few studies with indirect evidence, a simulation-based training study, and narrative reviews were identified. Currently organized training in NIV is implemented only in a few developed countries. Due to a lack of high-grade experimental evidence, an international consensus on NIV education and training based on opinions from 64 experts across the twenty-one different countries of the world was formulated. Education and training have the potential to increase knowledge and skills of the clinical staff who deliver medical care using NIV. There is a genuine need to develop structured, organized NIV education and training programs, especially for the developing countries.
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http://dx.doi.org/10.5603/ARM.a2019.0006DOI Listing
February 2020

Impact of sleep alterations on weaning duration of mechanically ventilated patients: how much is bad?

Eur Respir J 2018 07 4;52(1). Epub 2018 Jul 4.

Dept of Anaesthesiology and Critical Care, All India Institute of Medical Sciences, Raipur, India.

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http://dx.doi.org/10.1183/13993003.00925-2018DOI Listing
July 2018
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