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BackgroundUse of bubble continuous positive airway pressure (CPAP) has generated considerable interest in neonatal care, but its comparative effectiveness compared with other forms of CPAP, especially in developed countries, remains unclear.ObjectiveTo systematically review and meta-analyse short-term clinical outcomes among preterm infants treated with bubble CPAP vs all other forms of CPAP.MethodsProspective experimental studies published from 1995 onward until October 2018 comparing bubble versus other CPAP forms in preterm neonates <37 weeks’ gestational age were included after a systematic review of multiple databases using pre-specified search criteria.ResultsA total of 978 articles were identified, of which 19 articles were included in meta-analyses. Of these, 5 had a high risk of bias, 8 had unclear risk and 6 had low risk. The risk of the primary outcome (CPAP failure within 7 days) was lower with bubble CPAP (0.75; 95% CI 0.57 to 0.98; 12 studies, 1194 subjects, I2=21%). Among secondary outcomes, only nasal injury was higher with use of bubble CPAP (risk ratio (RR) 2.04, 95% CI 1.33 to 3.14; 9 studies, 983 subjects; I2=42%) whereas no differences in mortality (RR 0.82, 95% CI 0.47 to 1.92; 9 studies, 1212 subjects, I2=20%) or bronchopulmonary dysplasia (BPD) (RR 0.8, 95% CI 0.53 to 1.21; 8 studies, 816 subjects, I2=0%) were noted.ConclusionBubble CPAP may lead to lower incidence of CPAP failure compared with other CPAP forms. However, it does not appear to translate to improvement in mortality or BPD and potential for nasal injury warrants close monitoring during clinical application.Trial registration numberCRD42019120411.

Obstructive sleep apnea (OSA) is a common disease which impacts quality of life, mood, cardiovascular morbidity, and mortality. Continuous positive airway pressure (CPAP) is the first-line treatment for patients with moderate to severe OSA. CPAP ameliorates respiratory disturbances, leading to improvements in daytime sleepiness, quality of life, blood pressure, and cognition. However, despite the high efficacy of this device, CPAP adherence is often sub-optimal. Factors including: socio-demographic/economic characteristics, disease severity, psychological factors, and side-effects are thought to affect CPAP adherence in OSA patients. Intervention studies have suggested that augmented support/education, behavioral therapy, telemedicine and technological interventions may improve CPAP adherence. In this paper, we will extensively review the most common factors including age, gender, race/ethnicity, socioeconomic status, smoking status, severity of OSA, severity of OSA symptoms, psychological variables, social support, marital status/bed partner involvement, dry nose and mouth, mask leak, and nasal congestion that may predict CPAP adherence. We will also extensively review interventions that may increase adherence to CPAP.

Continuous positive airway pressure (CPAP) is considered the treatment of choice for obstructive sleep apnea (OSA), and studies have shown that there is a correlation between patient adherence and treatment outcomes. Newer CPAP machines can track adherence, hours of use, mask leak, and residual apnea-hypopnea index (AHI). Such data provide a strong platform to examine OSA outcomes in a chronic disease management model. However, there are no standards for capturing CPAP adherence data, scoring flow signals, or measuring mask leak, or for how clinicians should use these data. American Thoracic Society (ATS) committee members were invited, based on their expertise in OSA and CPAP monitoring. Their conclusions were based on both empirical evidence identified by a comprehensive literature review and clinical experience. CPAP usage can be reliably determined from CPAP tracking systems, but the residual events (apnea/hypopnea) and leak data are not as easy to interpret as CPAP usage and the definitions of these parameters differ among CPAP manufacturers. Nonetheless, ends of the spectrum (very high or low values for residual events or mask leak) appear to be clinically meaningful. Providers need to understand how to interpret CPAP adherence tracking data. CPAP tracking systems are able to reliably track CPAP adherence. Nomenclature on the CPAP adherence tracking reports needs to be standardized between manufacturers and AHIFlow should be used to describe residual events. Studies should be performed examining the usefulness of the CPAP tracking systems and how these systems affect OSA outcomes.

IntroductionThe use of non-invasive respiratory support for COVID-19 related respiratory failure outside of Intensive Care Units (ICU), delivered in respiratory support units, became widespread during the COVID-19 pandemic. There is paucity of data thus far for outcomes in this patient cohort.MethodsWe retrospectively reviewed the medical notes of 89 patients with COVID-19 pneumonitis admitted to our recently opened (April 2020) Respiratory Support Unit (RSU) at Colchester General Hospital from 17th April, 2020 to 13th February, 2021. Mean age was 69 years (range 30 – 93 years) and 56 patients were male. Sixty three patients received continuous positive airway pressure (CPAP), 6 patients received high flow nasal oxygen (HFNO), 13 patients received a combination of CPAP with periods of HFNO and 7 patients received non-invasive ventilation (NIV).ResultsOn admission to the RSU, patients had average saturations of 87.5% (range 50 – 99%) with an average pO2 of 7.69kPa (range 3.6 – 18). The majority of patients were receiving fraction of inspired oxygen (FiO2) greater than 0.6. RSU success (wean from CPAP/NIV/HFNO) was 24.7%. RSU failure (either escalation to ICU or death, depending on treatment-escalation status) was 75.3%. The overall mortality rate was 71.9%. Mortality was higher (80%) in those patients who were not for escalation to ICU. Mortality in those for full treatment escalation was 42.1%. Higher mortality occurred in patients with multiple comorbidities, increasing age and higher Rookwood Clinical frailty scores (CFS). Patients without any additional organ dysfunction had lower mortality (62.5% vs 87.9%). Increasing mortality was observed with increasing time from hospital arrival to RSU admission. All patients aged 80 years or above and those with a CFS 6 died. Complications included pulmonary embolism (n=3), pneumothorax (n=1) and pneumomediastinum (n=1).Abstract P214 Table 1Mortality by groups Age groups 30– 39 40– 49 50– 59 60– 69 70– 79 >80 Mortality (%) 0 40 50 71.4 79.5 100 CFS 1 2 3 4 5 6 Mortality (%) 20 43 79 77.3 87.5 100 Number of comorbidities 0 1 2 3 4 Mortality (%) 42.9 46.1 76.9 80 84.6 Time to admission to RSU (days) Less than 1 1- 2 3- 7 8 or more Mortality (%) 63.2 64.7 81.5 81.8 ConclusionThese data demonstrate the high mortality in patients with respiratory failure secondary to COVID-19 pneumonitis admitted to our RSU, particularly in those who were not for escalation to ICU. Increasing age, number of comorbidities and CFS were associated with treatment failure as well as time between presentation and admission to RSU. Careful patient selection with consideration of these factors is vital when identifying patients appropriate for respiratory support.

Background Studies have shown that a significant percentage of patients with obstructive sleep apnea (OSA) do not tolerate continuous positive airway pressure (CPAP) therapy and long-term use may be as low as 30%. Given the lower levels of symptoms and health-related risks, patients with mild sleep apnea may be at even higher risk for non-adherence to long term CPAP. The purpose of our study was to investigate the prevalence and associations of long-term CPAP adherence in first time users with mild sleep apnea diagnosed by home sleep apnea testing (HSAT). Methods We identified all the patients who were diagnosed with mild sleep apnea (5 = < AHI < 15) by home sleep apnea testing from 01/2013 to 06/2019 at a large, combined community and hospital-based sleep practice. Only first time CPAP users were included. Compliance was defined as CPAP usage ≥ 4 h per night on ≥ 70% of nights over 30 consecutive days. We defined long term adherence as compliance on the 12th month following CPAP set up. Patient demographics, comorbidities, and CPAP compliance at 1st, 3rd, 6th, 9th and 12th month after therapy initiation were collected. We compared and identified the factors that had significant difference (P < 0.1) between compliant and non-compliant groups at the 12th month. Results 222 patients were included in the analysis. 57 (25.7%) patients were adherent with long term CPAP treatment. The following factors were associated with a greater likelihood for long-term CPAP adherence: older age, lower body mass index (BMI), presence of a bed partner, non-smoker, presence of Diabetes Mellitus (DM), presence of Heart Failure (CHF), lack of depression, and compliance at 1st, 3rd, 6th and 9th month. Conclusions Long term CPAP compliance in mild sleep apnea patients is low. Long term adherence to CPAP can be predicted based on CPAP adherence during the first three months.

Abstract Central sleep apnea is not a single disorder; it can present as an isolated disorder or as a part of other clinical syndromes. In some conditions, such as heart failure, central apneic events are due to transient inhibition of ventilatory motor output during sleep, owing to the overlapping influences of sleep and hypocapnia. Specifically, the sleep state is associated with removal of wakefulness drive to breathe; thus, rendering ventilatory motor output dependent on the metabolic ventilatory control system, principally PaCO2. Accordingly, central apnea occurs when PaCO2 is reduced below the “apneic threshold”. Our understanding of the pathophysiology of central sleep apnea has evolved appreciably over the past decade; accordingly, in disorders such as heart failure, central apnea is viewed as a form of breathing instability, manifesting as recurrent cycles of apnea/hypopnea, alternating with hyperpnea. In other words, ventilatory control operates as a negative—feedback closed-loop system to maintain homeostasis of blood gas tensions within a relatively narrow physiologic range, principally PaCO2. Therefore, many authors have adopted the engineering concept of “loop gain” (LG) as a measure of ventilatory instability and susceptibility to central apnea. Increased LG promotes breathing instabilities in a number of medical disorders. In some other conditions, such as with use of opioids, central apnea occurs due to inhibition of rhythm generation within the brainstem. This review will address the pathogenesis, pathophysiologic classification, and the multitude of clinical conditions that are associated with central apnea, and highlight areas of uncertainty.

The role of non-invasive respiratory support (high-flow nasal oxygen and noninvasive ventilation) in the management of acute hypoxemic respiratory failure and acute respiratory distress syndrome is debated. The oxygenation improvement coupled with lung and diaphragm protection produced by non-invasive support may help to avoid endotracheal intubation, which prevents the complications of sedation and invasive mechanical ventilation. However, spontaneous breathing in patients with lung injury carries the risk that vigorous inspiratory effort, combined or not with mechanical increases in inspiratory airway pressure, produces high transpulmonary pressure swings and local lung overstretch. This ultimately results in additional lung damage (patient self-inflicted lung injury), so that patients intubated after a trial of noninvasive support are burdened by increased mortality. Reducing inspiratory effort by high-flow nasal oxygen or delivery of sustained positive end-expiratory pressure through the helmet interface may reduce these risks. In this physiology-to-bedside review, we provide an updated overview about the role of noninvasive respiratory support strategies as early treatment of hypoxemic respiratory failure in the intensive care unit. Noninvasive strategies appear safe and effective in mild-to-moderate hypoxemia (PaO 2 /FiO 2  > 150 mmHg), while they can yield delayed intubation with increased mortality in a significant proportion of moderate-to-severe (PaO 2 /FiO 2  ≤ 150 mmHg) cases. High-flow nasal oxygen and helmet noninvasive ventilation represent the most promising techniques for first-line treatment of severe patients. However, no conclusive evidence allows to recommend a single approach over the others in case of moderate-to-severe hypoxemia. During any treatment, strict physiological monitoring remains of paramount importance to promptly detect the need for endotracheal intubation and not delay protective ventilation.

The correct type and time of follow-up for patients affected by COVID-19 ARDS is still unclear. The aim of this study was to evaluate the survivors of COVID-19 ARDS requiring non-invasive respiratory support (NRS) admitted to a Respiratory Intensive care unit (RICU) from March 8th till May 31st 2020 looking at all sequelae via a comprehensive follow up. All patients underwent a multi-discipliry instrumental and clinical assessment within three months form admission to evaluate all infection related sequelae. Thirty-eight patients were enrolled lung-ultrasound (LUS) showed an outstanding discrimition ability (ROC AUC: 0.95) and a substantial agreement rate (Cohen’s K: 0.74) compared to chest CT-scan detecting improvement of lung consolidations. Youden’s test showed a cut-off pressure of 11 cm H2O ExpiratoryPAP-continuous-PAP-max (EPAP-CPAP) applied at the airways during hospitalization to be significantly correlated (p-value=0.026) to the increased pulmory artery common trunk diameter. A total of 8/38 patients (21.8%), 2 of whom during follow-up, were diagnosed with pulmory emboli (PE) and started anticoagulant treatment. Patients with PE had a statistically significant shorter length of time of hospitalization, time to negative swab, CPAP/NIV duration, P/F ratio and D-dimers at follow-up compared to non-PE. A comprehensive approach to patients with ARDS COVID-19 requiring NRS is necessary. This study highlighted cardiopulmory impairment related to the ARDS and to the high-EPAP-CPAP-max greater than 11 mmHg provided during admission, the usefulness of LUS in monitoring post-infection recovery and the correct identification and treatment of patients with PE during follow up.

Morbidly obese patients are in the group of patients, who can desaturate fast because of changes in lung volumes and reduction in Functional Residual Capasity due to obesity. There are novel methods to improve preoxygenation and to maintain oxygneation during intubation efforts. In this paper we present methods of apneic oxygenation for morbidly obese patients.Morbidly obese patients are in the group of patients, who can desaturate fast because of changes in lung volumes and reduction in Functional Residual Capasity due to obesity. There are novel methods to improve preoxygenation and to maintain oxygneation during intubation efforts. In this paper we present methods of apneic oxygenation for morbidly obese patients.

Abstract Study Objectives To examine associations between positive airway pressure (PAP) therapy, adherence and incident diagnoses of Alzheimer’s disease (AD), mild cognitive impairment (MCI), and dementia not otherwise specified (DNOS) in older adults. Methods This retrospective study utilized Medicare 5% fee-for-service claims data of 53,321 beneficiaries, aged 65 and older, with an obstructive sleep apnea (OSA) diagnosis prior to 2011. Study participants were evaluated using ICD-9 codes for neurocognitive syndromes (AD [n = 1,057], DNOS [n = 378], and MCI [n = 443]) that were newly identified between 2011 and 2013. PAP treatment was defined as the presence of at least one durable medical equipment (Healthcare Common Procedure Coding System [HCPCS]) code for PAP supplies. PAP adherence was defined as at least two HCPCS codes for PAP equipment, separated by at least 1 month. Logistic regression models, adjusted for demographic and health characteristics, were used to estimate associations between PAP treatment or adherence and new AD, DNOS, and MCI diagnoses. Results In this sample of Medicare beneficiaries with OSA, 59% were men, 90% were non-Hispanic whites and 62% were younger than 75 years. The majority (78%) of beneficiaries with OSA were prescribed PAP (treated), and 74% showed evidence of adherent PAP use. In adjusted models, PAP treatment was associated with lower odds of incident diagnoses of AD and DNOS (odds ratio [OR] = 0.78, 95% confidence interval [95% CI]: 0.69 to 0.89; and OR = 0.69, 95% CI: 0.55 to 0.85). Lower odds of MCI, approaching statistical significance, were also observed among PAP users (OR = 0.82, 95% CI: 0.66 to 1.02). PAP adherence was associated with lower odds of incident diagnoses of AD (OR = 0.65, 95% CI: 0.56 to 0.76). Conclusions PAP treatment and adherence are independently associated with lower odds of incident AD diagnoses in older adults. Results suggest that treatment of OSA may reduce the risk of subsequent dementia.