Telemedicine as a means of remote patient-physician interaction is gaining popularity in nearly every field, and (respiratory) sleep medicine is no exception. Because obstructive sleep apnoea (OSA) is a chronic condition, and requires a continuous treatment and monitoring of therapy success, telematic communications could be useful to establish diagnostic and therapeutic strategies. This statement summarises the evidence and efficacy of telemedicine options in OSA. An interdisciplinary European Respiratory Society (ERS) task force evaluated the scientific literature based on a systematic search and two-step screening process (title/abstract and full text). Although the task force does not make recommendations for clinical practice, it describes its current practice of telemedicine applications in OSA. The literature shows that telemedicine has been studied in different areas of OSA management, with potential benefits. Telemedicine also served as a major research tool to provide big data related to positive airway pressure therapy. Telemedicine results in similar or improved compliance when compared with traditional face-to-face encounters. Telemedicine-based targeted troubleshooting and support based on individual patient data, and a combination via smartphone apps or coaching websites, are feasible and effective. Expanding evidence suggests that telemedicine is probably cost-effective. However, data do not consistently support staff time savings through telemedicine-based solutions. The potential benefits of telemedicine include improved access to healthcare, and increased adherence to (chronic illness) treatment plans. Benefits should be weighed against the overall costs of telemedicine and risks related to suboptimal compliance.

Objectives/Introduction: Obstructive Sleep Apnoea (OSA) is a heterogeneous condition with different clinical presentation between genders. This study aimed to identify specific OSA phenotypes in women in the ESADA database. Methods: Latent class analysis was applied to data from 9,710 females among 32,700 ESADA participants. Clusters were built using: age, Body Mass Index (BMI), Epworth Sleepiness Scale (ESS), co-morbidities (cardiovascular, pulmonary, psychiatric, metabolic, other) and Apnea Hypopnea Index (AHI). Results: Four different clusters were revealed: Cluster 1 "Women with ischemic heart disease" (38.3%): middle aged women, overweight with moderate OSA[AHI: 22.9/h [17.4; 30]],non-sleepy(ESS: 9 [5; 12])characterized by ischemic heart disease (56%). Cluster 2 "Elderly women with co-morbidities" (23%): elderly (66 years[60-71]), obese (36 kg/m2, [31.6-40.4]) patients with severe OSA (AHI: 46 events/h, [30 -60.1]) but no sleepiness (ESS 9, [6-13] )and the highest degree of co-morbidities. Cluster 3: "Sleepy obese women" (16.2 %):the youngest (49 years [42- 55]), sleepiest (ESS 12, [8-16])patients with the highest BMI (43kg/m2[37.6 ; 48.9]), severe OSA (AHI 53.3 events /h, [32- 80.5]), psychiatric disease (22.7%) and asthma (13.9%).Cluster 4: "Women with mild OSA and low co-morbidities" (22.5 %): middle aged, overweight non-sleepy (ESS: 9 [5; 13]) women with mild OSA(AHI 8.6events/h [6.9 ; 10.4])with low co-morbidities. PAP adherence was higher in Clusters 2 and 3 but low in Cluster 4. Conclusion: Four distinct women phenotypes with different clinical presentation and co-morbidities were identified. Gender-based phenotypes may be relevant for patient's risk stratification and personalized treatment.

Background: Decreased levels of serum 25(OH)D, i.e., the best indicator of vitamin D supply to the body, have been reported both in COPD and OSA patients, while continuous positive airway pressure (CPAP) therapy has been shown to improve hypovitaminosis D. Aim: To evaluate the effect of CPAP treatment on serum 25(OH)D levels in patients with coexistent COPD-OSA overlap syndrome (OS). Methods: In consecutive OS patients, (diagnosed with pulmonary function testing and polysomnography), serum 25(OH)D levels, Epworth sleepiness scale (ESS) score and COPD assessment test (CAT) score were measured at baseline and 12 months after CPAP treatment. Compliance to treatment was assessed from the data retrieved from the CPAP device. Results: Overall, 46 patients (43 males, mean age 60.9 years, mean BMI 37.8±5.5 Kg/m2, GOLD stage B 43.5%) were included and evaluated over a 12-month period. Most of the patients (82.6%) had severe OSA. After 12 months, the majority of patients shifted from COPD GOLD stage B to stage A. After 12 months of treatment, an improvement was observed in apnea-hypopnea index (AHI) (from 41.1/h to 3.1/h, p<0.001), ESS score (from 9 to 3, p<0.001] and CAT score (from 9 to 5, p<0.001). In all patients, serum 25(OH)D levels increased after 12 months of CPAP (from 21.3±8.4 to 23.8±8.7 ng/ml, p=0.001). Those were higher in OS patients with good 12-month CPAP compliance compared to patients with poor compliance (25.8±7.6 versus 20.4±9.6 ng/ml, p = 0.038). Conclusions: In a sample of OS patients, good compliance to CPAP treatment was proven to be associated with improvement in OSA and COPD indices, as well as with an increase in serum 25(OH)D levels.

Abstract Introduction Patients with overlap syndrome (OS), that is obstructive sleep apnea (OSA) and chronic obstructive pulmonary disease (COPD), are at increased risk of acute exacerbations related to COPD (AECOPD). We assessed the effect of CPAP compliance on AECOPD, symptoms and pulmonary function in OS patients. Methods Consecutive OS patients underwent assessment at baseline and at 12 months under treatment with CPAP of: AECOPD and hospitalizations, COPD Assessment Test (CAT) and modified British Medical Research Council (mMRC) questionnaires, pulmonary function testing and 6‐min walking test (6MWT). Results In total, 59 patients (54 males) with OS were followed for 12 months and divided post hoc according to CPAP compliance into: group A with good (≥4 h CPAP use/night, n = 29) and group B with poor (<4 h CPAP use/night, n = 30) CPAP compliance. At 12 months, group A showed improvements in FEV1 (p = 0.024), total lung capacity (p = 0.024), RV/TLC (p = 0.003), 6MWT (p < 0.001) and CAT (p < 0.001). COPD exacerbations decreased in patients with good CPAP compliance from baseline to 12 months (17 before vs. 5 after, p = 0.001), but not in those with poor compliance (15 before vs. 15 after, p = 1). At multivariate regression analysis, COPD exacerbations were associated with poor CPAP compliance (β = 0.362, 95% CI: 0.075–0.649, p = 0.015). Conclusions When compared to poorly compliant patients, OS patients with good CPAP compliance had a lower number of AECOPD and showed improved lung function and COPD related symptoms.

Obstructive sleep apnoea is a challenging medical problem due to its prevalence, its impact on quality of life and performance in school and professionally, the implications for risk of accidents, and comorbidities and mortality. Current research has carved out a broad spectrum of clinical phenotypes and defined major pathophysiological components. These findings point to the concept of personalised therapy, oriented on both the distinct clinical presentation and the most relevant pathophysiology in the individual patient. This leads to questions of whether sufficient therapeutic options other than positive airway pressure (PAP) alone are available, for which patients they may be useful, if there are specific indications for single or combined treatment, and whether there is solid scientific evidence for recommendations. This review describes our knowledge on PAP and non-PAP therapies to address upper airway collapsibility, muscle responsiveness, arousability and respiratory drive. The spectrum is broad and heterogeneous, including technical and pharmaceutical options already in clinical use or at an advanced experimental stage. Although there is an obvious need for more research on single or combined therapies, the available data demonstrate the variety of effective options, which should replace the unidirectional focus on PAP therapy.

Obstructive sleep apnoea (OSA) is highly prevalent and is a recognised risk factor for motor vehicle accidents (MVA). Effective treatment with continuous positive airway pressure has been associated with a normalisation of this increased accident risk. Thus, many jurisdictions have introduced regulations restricting the ability of OSA patients from driving until effectively treated. However, uncertainty prevails regarding the relative importance of OSA severity determined by the apnoea-hypopnoea frequency per hour and the degree of sleepiness in determining accident risk. Furthermore, the identification of subjects at risk of OSA and/or accident risk remains elusive. The introduction of official European regulations regarding fitness to drive prompted the European Respiratory Society to establish a task force to address the topic of sleep apnoea, sleepiness and driving with a view to providing an overview to clinicians involved in treating patients with the disorder. The present report evaluates the epidemiology of MVA in patients with OSA; the mechanisms involved in this association; the role of screening questionnaires, driving simulators and other techniques to evaluate sleepiness and/or impaired vigilance; the impact of treatment on MVA risk in affected drivers; and highlights the evidence gaps regarding the identification of OSA patients at risk of MVA.

Treatment of obstructive sleep apnoea (OSA) in adults is evolving, as new therapies have been explored and introduced in clinical practice, while other approaches have been refined or reconsidered. In this European Respiratory Society (ERS) guideline on non-continuous positive airway pressure (CPAP) therapies for OSA, we present recommendations determined by a systematic review of the literature. It is an update of the 2011 ERS statement on non-CPAP therapies, advanced into a clinical guideline. A multidisciplinary group of experts, including pulmonary, surgical, dentistry and ear–nose–throat specialists, methodologists and patient representatives considered the most relevant clinical questions (for both clinicians and patients) relating to the management of OSA. Eight key clinical questions were generated and a systematic review was conducted to identify published randomised clinical trials that answered these questions. We used the GRADE (Grading of Recommendations Assessment, Development and Evaluation) approach to assess the quality of the evidence and the strength of recommendations. The resulting guideline addresses gastric bypass surgery, custom-made dual-block mandibular advancement devices, hypoglossal nerve stimulation, myofunctional therapy, maxillo-mandibular osteotomy, carbonic anhydrase inhibitors and positional therapy. These recommendations can be used to benchmark quality of care for people with OSA across Europe and to improve outcomes.

Background and objective To personalize OSA management, several studies have attempted to better capture disease heterogeneity by clustering methods. The aim of this study was to conduct a cluster analysis of 23 000 OSA patients at diagnosis using the multinational ESADA. Methods Data from 34 centres contributing to ESADA were used. An LCA was applied to identify OSA phenotypes in this European population representing broad geographical variations. Many variables, including symptoms, comorbidities and polysomnographic data, were included. Prescribed medications were classified according to the ATC classification and this information was used for comorbidity confirmation. Results Eight clusters were identified. Four clusters were gender-based corresponding to 54% of patients, with two clusters consisting only of men and two clusters only of women. The remaining four clusters were mainly men with various combinations of age range, BMI, AHI and comorbidities. The preferred type of OSA treatment (PAP or mandibular advancement) varied between clusters. Conclusion Eight distinct clinical OSA phenotypes were identified in a large pan-European database highlighting the importance of gender-based phenotypes and the impact of these subtypes on treatment prescription. The impact of cluster on long-term treatment adherence and prognosis remains to be studied using the ESADA follow-up data set.

Background: A novel multicomponent grading system for obstructive sleep apnoea (OSA) severity has been proposed. It includes symptom burden and end-organ impact to classify patients in four groups (“Baveno classification”*). The current study applied this classification in a large representative patient cohort. Methods: OSA patients from the European Sleep Apnoea Data Base (ESADA) cohort, collected from 2007 onwards in 20 countries were categorized according to symptoms (Epworth Sleepiness Scale Score ≥9, subjective sleep length ≥11h, diagnosis of insomnia) and major end-organ impact (uncontrolled arterial hypertension, atrial fibrillation, heart failure, diabetes, and history of stroke). Results: 14499 patients (28% female, 54±12 years, BMI 33±7 kg/m²) were categorized. Each Baveno class comprised a relevant proportion of patients. The percentage sleep time with oxygen saturation below 90% (T90) was elevated in patients with either severe symptoms or major end-organ impact and even further increased if both conditions coincided (table 1). Conclusion: Our data show that the four suggested OSA phenotypes of the “Baveno” classification reflect clinical phenotypes in a large, representative European patient cohort. The impact of T90, known to be correlated with poor cognitive, cardiovascular and metabolic outcomes, may indicate the prognostic relevance of the grading system. * Randerath et al. ERJ 2018; 52: 1702616

Background: Gender affects the clinical presentation of obstructive sleep apnea (OSA). The classic OSA symptoms, such as sleepiness, snoring, and apnea, are not so frequent in women. Objectives: To evaluate possible gender differences in questionnaires used for OSA prediction, such as the Epworth Sleepiness Scale (ESS), STOP, STOP Bang (SB), Berlin Questionnaire (BQ), Athens Insomnia Scale (AIS), and Fatigue Scale (FS). Methods: 350 males were matched with 350 women referred to a sleep clinic, according to OSA severity. All responded to the questionnaires and underwent a sleep study. Cardiovascular disease (CVD) patients were separately analyzed. Results: ESS did not differ between genders. SB was higher in males, whereas STOP, BQ, AIS, and FS were higher in females. BQ presented the highest sensitivity in both genders, whereas STOP exhibited the highest specificity in males and ESS in females. AIS and FS were more sensitive and SB more specific in females, whereas BQ was more specific in males. For severe OSA, the predictive values of SB and BQ were almost similar for both genders; however AIS and FS were higher in women. CVD patients presented higher scores, independent of gender, except for AIS, which was higher in females. Conclusion: Gender-specific evaluation of questionnaires is necessary to prevent OSA under-diagnosis.

Abstract Introduction Positive airway pressure (PAP) treatment modifies blood pressure (BP) in patients with obstructive sleep apnea (OSA). We aimed to explore which factors that influence the BP response to PAP therapy in the European Sleep Apnea Database (ESADA). Methods A total of 2662 OSA patients with PAP therapy ≥90 days were included in the analysis (74% male, age 55±11 years, body mass index 32.3±6.1 kg/m2, 47% hypertensives, apnea-hypopnea index 40±24 events/h, treatment duration 1.0±1.1 years, PAP compliance 5.2±1.9 h/day). Anthropometric data, co-medications and office BP were assessed at baseline and follow-up visit. Results Systolic and diastolic BP were modestly reduced after PAP therapy compared to baseline (133±17 vs. 134±17 mmHg, 78±11 vs. 81±11 mmHg, p<0.001, respectively). In a generalized linear model controlling for anthropometric, PAP compliance and follow-up time, severe OSA at baseline (β [95% CI] −3.2 [−5.1 to −1.3], p=0.001), hypertension status (−2.0 [−3.3 to −0.7], p=0.003), weight reduction >2 kg at follow up (−2.0 [−3.7 to −0.4], p=0.016), and use of auto-adjusted PAP (−1.3 [−2.5 to −0.02], p=0.046) were associated with a reduction of systolic BP at follow-up. Conclusions BP reduction following PAP treatment in patients with moderate to severe OSA was modest. We identified several predictors of a favorable BP response including the use of auto adjusted PAP. Our findings suggest that weight reduction strategies in addition to PAP treatment should be considered to obtain adequate BP control in OSA patients. Funding Acknowledgement Type of funding source: Other. Main funding source(s): European Respiratory Society funded Clinical Research Collaboration (2015-2020)

Central sleep apnoea (CSA) including periodic breathing is prevalent in more than one-third of patients with heart failure and is highly and independently associated with poor outcomes. Optimal treatment is still debated and well-conducted studies regarding efficacy and impact on outcomes of available treatment options are limited, particularly in cardiac failure with preserved ejection fraction. While continuous positive airway pressure and oxygen reduce breathing disturbances by 50%, adaptive servoventilation (ASV) normalises breathing disturbances by to controlling the underlying mechanism of CSA. Results are contradictory regarding impact of ASV on hard outcomes. Cohorts and registry studies show survival improvement under ASV, while secondary analyses of the large SERVE-HF randomised trial showed an excess mortality in cardiac failure with reduced ejection fraction. The current priority is to understand which phenotypes of cardiac failure patients may benefit from treatment guiding individualised and personalised management.

COPD and obstructive sleep apnoea (OSA) are highly prevalent and different clinical COPD phenotypes that influence the likelihood of comorbid OSA. The increased lung volumes and low body mass index (BMI) associated with the predominant emphysema phenotype protects against OSA whereas the peripheral oedema and higher BMI often associated with the predominant chronic bronchitis phenotype promote OSA. The diagnosis of OSA in COPD patients requires clinical awareness and screening questionnaires which may help identify patients for overnight study. Management of OSA-COPD overlap patients differs from COPD alone and the survival of overlap patients treated with nocturnal positive airway pressure is superior to those untreated. Sleep-related hypoventilation is common in neuromuscular disease and skeletal disorders because of the effects of normal sleep on ventilation and additional challenges imposed by the underlying disorders. Hypoventilation is first seen during rapid eye movement (REM) sleep before progressing to involve non-REM sleep and wakefulness. Clinical presentation is nonspecific and daytime respiratory function measures poorly predict nocturnal hypoventilation. Monitoring of respiration and carbon dioxide levels during sleep should be incorporated in the evaluation of high-risk patient populations and treatment with noninvasive ventilation improves outcomes.

Introduction and Aim: Obstructive sleep apnea (OSA) is an independent risk factor for dyslipidemia and nocturnal hypoxia plays an important role in this association. The aim of the current study was to examine the effects of OSA alleviation by PAP treatment on cholesterol levels. Methods: In the present prospective cohort study, 1564 OSA subjects from 9 centers of the ESADA database undergoing PAP therapy for at least 3 months were identified (mean age 54±11y, BMI 32.7±6.6kg/m2, 74% male and AHI 40.3±24.4 n/h). Baseline and follow-up total cholesterol concentrations were examined. Repeated measures and logistic regression tests (adjusted for age, gender, change in weight, lipid lowering medication use, PAP compliance and duration) were used for comparing the changes in cholesterol concentrations. Results: Estimated means of cholesterol decreased from 194.2 mg/dl to 189.3 mg/dl during follow up (p=0.019). 422 patients (27%) experienced a clinically significant (10%) reduction of total cholesterol at PAP follow up and duration of PAP therapy was identified as the only independent predictor of this reduction. The reduction of cholesterol corresponded to an overall CV risk reduction from 26.7% to 24.1% in males and from 11.2% to 10.1% in females according to the Framingham CVD risk score, p<0.001 both. Conclusion: The present study, being the largest study on this topic so far, demonstrated a significant decrease in total cholesterol after PAP treatment. Based on the close association of hypercholesterolemia with increased cardiovascular mortality, identification and treatment of OSA patients with dyslipidemia may have clinical significance.

OBJECTIVE/BACKGROUND:The Clinical Global Impression scale (CGI) reflects the clinician's assessment of the disease impact on patient's global functioning. We assessed predictors of CGI scale rating in patients with obstructive sleep apnea (OSA). PATIENTS/METHODS:Consecutive patients with suspected OSA (n = 7581) were identified in the European Sleep Apnea Database (ESADA). Anthropometrics, comorbidities, apnea severity obtained by polygraphy or polysomnography, and daytime sleepiness [Epworth Sleepiness Scale (ESS)] were assessed. The CGI 7-point scale was completed at the end of the diagnostic process (CGI-severity, ie, CGI-S) and, in a subpopulation, at treatment follow-up (CGI-Improvement). RESULTS:CGI-S was rated mild to moderate in 44% of patients. CGI rating at any given apnea intensity was worse in women than in men (p < 0.01). Patients undergoing polygraphy (n = 5075) were more frequently rated as severely ill compared to those studied with polysomnography (19.0% vs 13.0%, p < 0.001). In patients aged ≤65 years, CGI scoring was generally better than in the elderly despite a similar degree of OSA (eg, 'normal, not ill' 24.2% vs 15.3%, p < 0.01, respectively). Independent predictors of CGI rating included age, BMI, AHI, ESS, cardio-metabolic comorbidities, and diagnosis based on polygraphy. CGI-improvement rating (Beta = -0.406, p < 0.01) was superior to sleep apnea severity or ESS-score (Beta = 0.052 and -0.021, p = 0.154 and 0.538 respectively) at baseline for prediction of good CPAP compliance at follow-up. CONCLUSIONS:CGI rating is confounded by gender, age class and the type of sleep diagnostic method. As OSA phenotypes differ, CGI may contribute as a clinical tool to reflect the significance of clinical disease.

The effect of positive airway pressure treatment on weight and markers of central obesity in patients with obstructive sleep apnea remains unclear. We studied the change in body weight and anthropometric measures following positive airway pressure treatment in a large clinical cohort. Patients with obstructive sleep apnea with positive airway pressure treatment from the European Sleep Apnea Database registry (n = 1,415, 77% male, age 54 +/- 11 [mean +/- SD] years, body mass index 31.7 +/- 6.4 kg/m(2), apnea-hypopnea index 37 +/- 24 n per hr, Epworth Sleepiness Scale 10.2 +/- 5.0) were selected. Changes in body mass index and neck/waist/hip circumferences at baseline and at follow-up visit were analysed. Overall, body mass index (0.0 [95% confidence interval, -0.1 to 0.2] kg/m(2)) and neck circumference (0.0 (95% confidence interval, -0.1 to 0.1] cm) were unchanged after positive airway pressure treatment compared with baseline (follow-up duration 1.1 +/- 1.0 years and compliance 5.2 +/- 2.1 hr per day). However, in non-obese (body mass index <30 kg/m(2)) patients, positive airway pressure treatment was associated with an increased body mass index and waist circumference (0.4 [0.3-0.5] kg/m(2) and 0.8 [0.4-1.2] cm, respectively, all p < 0.05), and weight gain was significantly associated with higher positive airway pressure compliance and longer positive airway pressure treatment duration. In the obese subgroup, body mass index was reduced after positive airway pressure treatment (-0.3 [-0.5 to -0.1] kg/m(2), p < 0.05) mainly in patients with a strong reduction in Epworth Sleepiness Scale. In conclusion, positive airway pressure therapy was not found to systematically change body mass index in the European Sleep Apnea Database cohort, but the response was heterogeneous. Our findings suggest that weight gain may be restricted to an obstructive sleep apnea phenotype without established obesity. Lifestyle intervention needs to be considered in both lean and obese patients with obstructive sleep apnea receiving positive airway pressure treatment.

Background: Experimental and clinical studies suggest a relationship between Obstructive Sleep Apnea (OSA) and cancer development or progression Objectives: To explore the association between the severity of OSA and prevalence of cancer among patients reported to the European Sleep Apnea Database (ESADA) after control of several known risk factors for cancer development Methods: A prospective multicentre cohort study of adult patients with OSA (Apnea/Hypopnea Index, AHI≥5). OSA severity was classified according to AHI, Oxygen Desaturation Index (ODI) and % night-time spent with oxygen saturation <90%(TSat90). A cross-sectional association between OSA and cancer prevalence was assessed at the time of the baseline visit in the database using logistic regression analysis. Results: Of 19,556 participants, 357 (1.8%, 59.4% male) had been diagnosed with malignancy. Patients with malignancy were older (p<0,001), had lower body mass index (BMI) (p=0.004) and neck circumference (p=0.001). AHI, ODI, TSat90, Epworth Sleepiness Scale (ESS), Subjective sleep length and latency did not differ between patients with/without malignancy. Total Sleep Time (p=0.02) was lower in patients with malignancy. In a multivariable regression analysis, the severity of OSA assessed by AHI or ODI was not significantly associated with cancer prevalence after adjustment for age, sex, BMI, smoking status and alcohol intake. However, in patients aged<50 years AHI≥5 was associated with increased risk of cancer (OR=2.47, 95%CI1.13- 5,44, p=0.024). Conclusion: In the large multicentric ESADA cohort there was an association between OSA (AHI cutoff 5) and a prevalent cancer diagnosis but only in patients aged below 50 years.