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Obstructive sleep apnea (OSA) is associated with systemic hypertension. Either overnight intermittent hypoxia, or the recurrent arousals that occur in OSA, could cause the daytime increases in blood pressure (BP). To establish the role of intermittent hypoxia in the increased morning BP in patients with OSA. Randomized, double-blinded, crossover trial assessing the effects of overnight supplemental oxygen versus air (sham) on morning BP, after continuous positive airway pressure (CPAP) withdrawal in patients with moderate to severe OSA. The primary outcome was the change in home morning BP after CPAP withdrawal for 14 nights, oxygen versus air. Secondary outcomes included oxygen desaturation index (ODI), apnea-hypopnea index (AHI), subjective sleepiness (Epworth Sleepiness Scale score), and objective sleepiness (Oxford Sleep Resistance Test). Supplemental oxygen virtually abolished the BP rise after CPAP withdrawal and, compared with air, significantly reduced the rise in mean systolic BP (-6.6 mm Hg; 95% confidence interval [CI], -11.3 to -1.9; P = 0.008), mean diastolic BP (-4.6 mm Hg; 95% CI, -7.8 to -1.5; P = 0.006), and median ODI (-23.8/h; interquartile range, -31.0 to -16.3; P < 0.001) after CPAP withdrawal. There was no significant difference, oxygen versus air, in AHI, subjective sleepiness, or objective sleepiness. Supplemental oxygen virtually abolished the rise in morning BP during CPAP withdrawal. Supplemental oxygen substantially reduced intermittent hypoxia, but had a minimal effect on markers of arousal (including AHI), subjective sleepiness, or objective sleepiness. Therefore intermittent hypoxia, and not recurrent arousals, appears to be the dominant cause of daytime increases in BP in OSA.

Publishing innovative and cutting-edge original research, Thorax aims to educate by highlighting significant advances in scientific understanding which are likely to impact on clinical practice. BTS, British Thoracic Society; MCQs, multiple-choice questions In response to the training survey, we have created an education landing page to provide a home for all educational content within Thorax. Journal club articles now focus on a single theme, for example, our recent offering focusing on biologics in asthma.3 We have also launched a new podcast in collaboration with the PulmPEEPS, which will be discussing four selected articles from the journal club on a quarterly basis.4 Finally, we are developing complimentary MCQs for selected articles which will help map educational content to trainees’ curriculums and provide continuing practice development credits for specialists.

The SARS-CoV-2 can lead to severe illness with COVID-19. Outcomes of patients requiring mechanical ventilation are poor. Awake proning in COVID-19 improves oxygenation, but on data clinical outcomes is limited. This single-centre retrospective study aimed to assess whether successful awake proning of patients with COVID-19, requiring respiratory support (continuous positive airways pressure (CPAP) or high-flow nasal oxygen (HFNO)) on a respiratory high-dependency unit (HDU), is associated with improved outcomes. HDU care included awake proning by respiratory physiotherapists. Of 565 patients admitted with COVID-19, 71 (12.6%) were managed on the respiratory HDU, with 48 of these (67.6%) requiring respiratory support. Patients managed with CPAP alone 22/48 (45.8%) were significantly less likely to die than patients who required transfer onto HFNO 26/48 (54.2%): CPAP mortality 36.4%; HFNO mortality 69.2%, (p=0.023); however, multivariate analysis demonstrated that increasing age and the inability to awake prone were the only independent predictors of COVID-19 mortality. The mortality of patients with COVID-19 requiring respiratory support is considerable. Data from our cohort managed on HDU show that CPAP and awake proning are possible in a selected population of COVID-19, and may be useful. Further prospective studies are required.

Obstructive sleep apnoea (OSA) was traditionally thought to be mainly caused by obesity and upper airway crowding, and hence OSA management was not personalised according to particular characteristics, with most symptomatic patients receiving continuous positive airway pressure therapy. Recent advances in our understanding have identified additional potential and distinct causes of OSA (endotypes), and subgroups of patients (phenotypes) with increased risk of cardiovascular complications. In this review, we discuss the evidence to date as to whether there are distinct clinically useful endotypes and phenotypes of OSA, and the challenges to the field in moving towards delivering personalised therapy in OSA.

Individuals with cancer, particularly those who are receiving systemic anticancer treatments, have been postulated to be at increased risk of mortality from COVID-19. This conjecture has considerable effect on the treatment of patients with cancer and data from large, multicentre studies to support this assumption are scarce because of the contingencies of the pandemic. We aimed to describe the clinical and demographic characteristics and COVID-19 outcomes in patients with cancer. In this prospective observational study, all patients with active cancer and presenting to our network of cancer centres were eligible for enrolment into the UK Coronavirus Cancer Monitoring Project (UKCCMP). The UKCCMP is the first COVID-19 clinical registry that enables near real-time reports to frontline doctors about the effects of COVID-19 on patients with cancer. Eligible patients tested positive for severe acute respiratory syndrome coronavirus 2 on RT-PCR assay from a nose or throat swab. We excluded patients with a radiological or clinical diagnosis of COVID-19, without a positive RT-PCR test. The primary endpoint was all-cause mortality, or discharge from hospital, as assessed by the reporting sites during the patient hospital admission. From March 18, to April 26, 2020, we analysed 800 patients with a diagnosis of cancer and symptomatic COVID-19. 412 (52%) patients had a mild COVID-19 disease course. 226 (28%) patients died and risk of death was significantly associated with advancing patient age (odds ratio 9·42 [95% CI 6·56–10·02]; p<0·0001), being male (1·67 [1·19–2·34]; p=0·003), and the presence of other comorbidities such as hypertension (1·95 [1·36–2·80]; p<0·001) and cardiovascular disease (2·32 [1·47–3·64]). 281 (35%) patients had received cytotoxic chemotherapy within 4 weeks before testing positive for COVID-19. After adjusting for age, gender, and comorbidities, chemotherapy in the past 4 weeks had no significant effect on mortality from COVID-19 disease, when compared with patients with cancer who had not received recent chemotherapy (1·18 [0·81–1·72]; p=0·380). We found no significant effect on mortality for patients with immunotherapy, hormonal therapy, targeted therapy, radiotherapy use within the past 4 weeks. Mortality from COVID-19 in cancer patients appears to be principally driven by age, gender, and comorbidities. We are not able to identify evidence that cancer patients on cytotoxic chemotherapy or other anticancer treatment are at an increased risk of mortality from COVID-19 disease compared with those not on active treatment. University of Birmingham, University of Oxford.

The effect of continuous positive airway pressure (CPAP) on cardiovascular events is uncertain in minimally symptomatic obstructive sleep apnoea. Previous 2-year follow-up data from the Multicentre Obstructive Sleep Apnoea Intervention Cardiovascular (MOSAIC) trial showed a marginal reduction in cardiovascular events with CPAP therapy. We now present long-term MOSAIC study follow-up data. Median (first quartile, third quartile) follow-up was 5.0 (2.2, 5.0) and 3.7 (1.5, 5.0) years for CPAP and standard care, respectively. Compared to standard care, CPAP had no statistically significant effect on the risk of cardiovascular events (HR=0.83, p=0.54, 95% CI 0.46–1.51).

IntroductionVibrotactile positional therapy (PT) devices are a new treatment modality for positional obstructive sleep apnoea (POSA). This review aimed to determine the effect of vibrotactile PT on the Apnoea Hypopnoea Index (AHI) and the percentage of time spent in the supine position (%Tsupine) in patients with POSA, compared with baseline. Secondary aims were to investigate the effect on daytime sleepiness, quality of life and sleep quality.MethodsA systematic review and meta-analysis was performed of randomised controlled trials (RCTs) and cohort studies that investigated the effect of vibrotactile PT in POSA patients. Searches were performed via MEDLINE, CENTRAL and Embase up to 29 October 2022.Results1119 studies were identified, 18 studies met the inclusion criteria (10 RCTs, 8 cohort studies). The use of vibrotactile PT significantly reduced the AHI at follow-up compared with baseline (mean difference (95% CI) −9.19 events/hour (–11.68 to –6.70); p<0.00001). The mean %Tsupine was also significantly reduced (mean difference (95% CI) −32.79% (–38.75% to –26.83%); p<0.00001). The percentage changes in the AHI and %Tsupine were 43% and 70%, respectively. Secondary outcomes were daytime sleepiness, quality of life and sleep indices. These showed minimal change, although follow-up was short.ConclusionVibrotactile PT devices are effective in treating POSA; reducing both AHI and %Tsupine. The effect on sleep quality, daytime sleepiness and disease-specific quality of life was minimal. However, there were limited data and follow-up was often brief, meaning that further research is needed to determine the effect of vibrotactile PT on patient-centred outcomes.PROSPERO registration numberCRD42020188617.

PurposeEndocan is a biomarker of endothelial dysfunction, which is a precursor to cardiovascular disease. Obstructive sleep apnoea (OSA) is associated with elevated endocan levels but the effects of treatment on endocan levels in OSA are not fully established. We aimed to determine whether endocan levels could be detected by immunoassay and to determine the effect of supplemental oxygen during continuous positive airway pressure (CPAP) withdrawal on circulating endocan levels.MethodsWe conducted an exploratory analysis from a randomised controlled crossover study which included participants with OSA. Participants stopped their CPAP therapy and were randomised to receive either supplemental oxygen or sham for 14 nights before crossing over. Supplemental oxygen blocked the rise in blood pressure seen in the sham group. We analysed plasma endocan levels by immunoassay at baseline and after 14 nights of intervention in both groups.ResultsTwenty-five participants were included, with a total of 100 samples. Endocan levels were detectable at all time points in 22 participants (88%), and in 93 (93%) samples. Supplemental oxygen had no effect on endocan levels compared to sham (+ 0.52 ng/ml, 95%CI -0.21 to + 1.25, p = 0.16), and there was no significant difference in endocan levels from baseline to follow-up in either the sham (-0.30 ng/ml, 95%CI -0.89 to + 0.30, p = 0.31) or supplemental oxygen (+ 0.22 ng/ml, 95%CI 0.00 to + 0.44, p = 0.05) arm.ConclusionsWe have shown that endocan levels are detectable before and after CPAP withdrawal. However, we found no effect of supplemental oxygen following CPAP withdrawal on circulating endocan levels.Trial registration and dateISRCTN 17,987,510 19/02/2015.