Search Results (408)

Background and Objectives: Adherence to positive airway pressure (PAP) is often suboptimal, and current monitoring relies on device logs that, by design, cannot detect respiratory events outside the therapy window. This creates a physiological blind spot during periods of non-usage. This study aimed to demonstrate the clinical necessity of independent, continuous monitoring using a smartphone-based home sleep apnea test (S-HSAT) by validating treatment effectiveness on adherent nights and quantifying the untreated apnea burden caused by partial adherence. Methods: We prospectively monitored 63 obstructive sleep apnea (OSA) patients commencing PAP therapy. Nightly apnea–hypopnea index (AHI) and usage time were recorded simultaneously by an S-HSAT (ApnoTrack) and the PAP device over a 30-day period. Nights were categorized by the duration discrepancy between S-HSAT and PAP (full-use, ≤5 min; intermediate-use, 5–30 min; partial-use, >30 min) using physiologically and operationally derived thresholds. Results: Final analysis included 39 participants contributing 667 nights (24 participants excluded due to non-use of one or both devices). Full-use nights (46.2%) showed close agreement between S-HSAT and PAP mean AHI (2.8 ± 4.3 vs. 2.5 ± 2.0 events/h; p = 0.13). On intermediate-use and partial-use nights (20.7% and 33.1%, respectively), substantial AHI discrepancies emerged (7.3 ± 5.5 vs. 3.8 ± 3.3 and 11.0 ± 7.4 vs. 2.8 ± 2.5 events/h, respectively; both p < 0.001). Conclusions: Independent S-HSAT monitoring quantified an untreated apnea burden that is invisible to PAP logs alone, while confirming therapeutic efficacy on well-adherent nights. These findings suggest that continuous independent monitoring may help bridge the gap between prescribed therapy and actual physiological outcomes in OSA care. Full article

Bronchopulmonary dysplasia (BPD) remains a major complication of extreme prematurity, driven in part by persistent inflammation. Interleukin (IL)-1–mediated signaling plays a central role in sustaining lung injury, making IL-1 blockade a potential therapeutic target. Evidence on the use of anakinra, a recombinant IL-1 receptor antagonist, in neonatal BPD is still limited. We report the case of a female preterm infant (28⁺² weeks’ gestation, birth weight 800 g, −1.41 zs) affected by BPD requiring prolonged respiratory support. Due to persistent respiratory failure despite standard therapies, off-label treatment with subcutaneous anakinra (5 mg/kg twice daily) was initiated at 150 days of life. Clinical respiratory parameters and exploratory salivary inflammatory biomarkers (IL-6 and soluble urokinase plasminogen activator receptor, suPAR) were longitudinally monitored. Following anakinra initiation, the patient showed a gradual improvement in respiratory parameters, with reduction in oxygen requirement, mean airway pressure, and improved gas exchange. Respiratory support was gradually de-escalated from nasal intermittent positive pressure ventilation to continuous positive airway pressure and subsequently to high-flow nasal cannula. Salivary suPAR levels demonstrated a decreasing trend, while IL-6 showed transient fluctuations, partly associated with intercurrent infections. Treatment was generally well tolerated during the observation period. The infant was discharged on minimal respiratory support, with continued improvement during follow-up. This case suggests a possible role of IL-1 blockade in the modulation of persistent inflammation in BPD with a refractory clinical course, although the observed clinical course may also reflect the natural evolution of the disease. Longitudinal salivary biomarkers may represent a feasible, exploratory, non-invasive approach to describe inflammatory dynamics over time. Larger prospective studies are needed to evaluate the efficacy, safety, and optimal treatment protocols of anakinra. Full article

Background: Non-invasive respiratory supports (High-Flow Nasal Oxygen, HFNO; Continuous Positive Airway Pressure, CPAP; Non-Invasive Ventilation, NIV) are frequently used in Acute Hypoxemic Respiratory Failure (AHRF). However, the experience of assisted breathing may profoundly affect patients’ psychological balance, particularly during acute critical illness and subsequent rehabilitation. Aims and objectives: This longitudinal study investigated the psychological burden associated with non-invasive respiratory support use in patients with COVID-19-related AHRF, exploring changes in psychological functioning from acute hospitalization (RICU/ICU) (T0) to follow-up, conducted at a mean of 6.0 ± 3.1 months after respiratory rehabilitation (T1). Methods: Fifty-two patients (mean age = 66.9 ± 9.17 years) were assessed at T0 and T1. Standardized measures evaluated anxiety, psychological distress, post-traumatic stress symptoms, depression, and resilience, in relation to perceived illness severity and subjective experience of non-invasive respiratory support. Results: During acute care, patients reported high levels of fear and anxiety related to illness severity and uncertainty. The experience of non-invasive respiratory support, often perceived as a marker of critical condition, was associated with increased fear and anxiety (t(14) = 2.79, p = 0.014) compared to the recovery phase, leading to feelings of loss of control and diminished psychological well-being (t(17) = 2.35, p = 0.031). However, resilience significantly improved over time (t(16) = −4.78, p < 0.001). Conclusions: Non-invasive respiratory support may represent a psychologically demanding experience, often perceived as challenging to patients’ sense of safety and control. Encouragingly, psychological adaptation and resilience can improve during rehabilitation. Integrating structured psychological support within respiratory rehabilitation pathways may promote recovery and restore psychological balance in patients requiring assisted ventilation. Full article

Obstructive sleep apnea (OSA) is a sleep-disordered breathing condition characterized by recurrent upper-airway obstruction, leading to intermittent hypoxemia, sleep fragmentation, and sympathetic activation. OSA is highly prevalent in patients with cardiovascular diseases and is strongly associated with hypertension, atrial fibrillation, coronary artery disease, heart failure, and adverse prognosis. This review summarizes current evidence on the pathophysiology of OSA, its cardiovascular consequences, and available diagnostic and therapeutic strategies, with particular attention to clinical implications in cardiology practice. We discuss established treatments such as lifestyle interventions, continuous positive airway pressure, mandibular advancement devices, and selected surgical options, as well as emerging therapies, including pharmacological approaches targeting weight loss and ventilatory control. While OSA treatment improves symptoms and quality of life, evidence for cardiovascular event reduction remains heterogeneous and appears strongly influenced by patient selection and treatment adherence. Identifying patients most likely to benefit from targeted OSA management remains a key challenge. Full article

Background and Objectives: Continuous positive airway pressure (CPAP) is the standard first-line treatment for patients with obstructive sleep apnea (OSA). Patients with OSA exhibit a higher prevalence of vitamin D deficiency, and CPAP treatment has been reported to improve vitamin D levels. Therefore, the aim of this study was to investigate the association between vitamin D deficiency and the risk of patients receiving a diagnosis of OSA or utilizing CPAP, using the TriNetX research network to obtain real-world data. Materials and Methods: A retrospective cohort study using the TriNetX database was conducted to investigate the relationship between vitamin D deficiency and patients with risk of receiving an OSA diagnosis or patients treated with CPAP in older adults (≥65 years). Patients were stratified into four groups according to serum 25-hydroxyvitamin D [25(OH)D] levels: severe deficiency (D10, ≤10 ng/mL), mild deficiency (D20, 11–20 ng/mL), insufficient vitamin D status (S30, 21–30 ng/mL), and normal vitamin D status (N100, 31–100 ng/mL). After 1:1 propensity score matching (PSM) to adjust for baseline covariates, patients were followed for up to 5 years for newly diagnosed OSA and CPAP use (an administrative-clinical outcome influenced by non-disease-related factors such as healthcare access and clinical practice), with vitamin D status assessed at the index date. An anchor-based network meta-analysis was also performed to integrate direct and indirect evidence across groups. Results: A total of 2,289,855 eligible patients were included and stratified into four groups: D10 (n = 161,610; 7.06%), D20 (n = 404,954; 17.68%), S30 (n = 648,989; 28.34%), and N100 (n = 1,074,302; 46.92%). Across the six pairwise comparisons, pre-matching baseline imbalances showed consistent patterns: lower vitamin D groups (particularly D10 and D20) generally had older age at index (in comparisons with S30 or D20), a higher proportion of males, and higher proportions of Black/African American patients, whereas higher vitamin D groups (especially N100 and S30) had higher proportions of White patients (and, in some comparisons, Asian patients). Comorbidity differences were modest overall, and these imbalances were substantially reduced after PSM. In both pairwise PSM analyses and the anchor-based network meta-analysis, severe vitamin D deficiency was observationally associated with the risk of receiving an OSA diagnosis and CPAP use. An observational trend appeared across vitamin D categories (D10 > D20 > S30), suggesting an association. The associations were strongest at 1 year and gradually attenuated over the 3- and 5-year follow-up periods. An E-value greater than 3 was observed only for the comparison between the D10 and N100 groups. Conclusions: In this real-world analysis of older adults, vitamin D deficiency, particularly severe deficiency, was observationally associated with increased 5-year risk of receiving an OSA diagnosis and CPAP use. Similarly, anchor-based network meta-analysis also showed an association between vitamin D deficiency severity and the risk of receiving an OSA diagnosis and CPAP use. Full article

Background/Objectives: Metabolic and bariatric surgery (MBS) is increasingly performed worldwide and requires specific anesthetic management due to the complex physiological alterations associated with severe obesity. Although several international guidelines provide recommendations for perioperative care in bariatric patients, their implementation in routine clinical practice may vary. This study aimed to report anesthetic practices among Polish anesthesiologists providing anesthesia for bariatric procedures. Methods: A cross-sectional survey study was conducted in October 2025 among Polish anesthesiologists. The questionnaire consisted of 13 closed-ended questions addressing demographic characteristics, anesthetic management and blood pressure management, including preoperative thresholds for postponement of elective surgery and intraoperative thresholds for pharmacological treatment of hypotension. The survey was distributed via social media platforms. Participation was anonymous and voluntary. Results: A total of 71 anesthesiologists participated in the study. The most commonly used intubation device was the Macintosh laryngoscope (57.7%), while videolaryngoscopy was used by 42.2% of respondents. Positive end-expiratory pressure (PEEP) was routinely applied by most respondents, with 63.4% adjusting its level according to patient body weight. Multimodal analgesia components were commonly used, with paracetamol (95.8%), dexamethasone (91.5%), metamizole (90.1%), and lignocaine (84.5%) being the most frequently administered drugs. Most anesthesiologists reported postponing elective surgery when blood pressure exceeded 180/110 mmHg. More experienced anesthesiologists more often considered lower thresholds for postponement of elective surgery (p = 0.006). Conclusions: Reported practices among surveyed anesthesiologists for MBS in Poland are generally consistent with international recommendations, particularly regarding the use of PEEP. However, variability remains in airway management strategies and the use of videolaryngoscopy, highlighting the need for continued education and broader implementation of evidence-based perioperative protocols. Full article

Non-invasive respiratory support (NRS) has become a cornerstone in the management of acute respiratory failure (ARF), offering an alternative or a bridge between conventional oxygen therapy (COT) and invasive mechanical ventilation (iMV). While NRS techniques—including non-invasive ventilation (NIV), continuous positive airway pressure (CPAP), and high-flow nasal oxygen (HFNO)—have demonstrated efficacy in reducing intubation rates and improving outcomes, patient tolerance and synchrony remain critical determinants of success. Analgosedation, the strategic use of analgesics and sedatives, has emerged as an important adjunctive therapy to optimise NRS delivery, reduce patient–ventilator asynchrony, and improve comfort. However, the delicate balance between adequate sedation and the preservation of spontaneous breathing, airway protection, and hemodynamic stability presents unique challenges. This comprehensive narrative review synthesises current evidence on analgosedation strategies during NRS use, examining pharmacological agents, their pharmacokinetic and pharmacodynamic properties, comparative studies, indications, monitoring parameters, clinical settings, and safety considerations. We also review existing guidelines, discuss special considerations in paediatric populations, and propose practical clinical approaches. Understanding the nuanced application of analgosedation is essential for clinicians to maximise therapeutic benefit while minimising risks of NRS treatment failure and adverse outcomes. Full article

Background: Continuous positive airway pressure (CPAP) is the most effective treatment for obstructive sleep apnoea (OSA). However, CPAP adherence in randomized controlled trials (RCTs) is frequently inadequate, potentially leading to an underestimation of the therapy’s true effect on relevant outcomes. The aim was to identify patient and study characteristics that predict adherence to CPAP therapy in RCTs. Methods: PubMed and the existing meta-analyses were searched (1984 to 31 December 2024). A study-level meta-analysis of RCTs comparing CPAP with inactive control in patients with OSA was conducted. Meta-regressions and subgroup analyses (<4 h vs. ≥5 h usage) were undertaken to identify the predictors of CPAP adherence. Risk-of-bias was assessed using the Cochrane RoB-2 tool. Results: In 136 RCTs reporting on CPAP use, including 8827 patients with OSA (55 [49.5–59.8] years, 77.4 [61.2–89.2]% male, BMI 31 [28.9–33.2] kg/m², Epworth Sleepiness Scale (ESS) 10.0 ± 2.8, apnoea–hypopnoea-index (AHI) 35.7 ± 13.4/h), mean nocturnal CPAP use was 4.5 ± 1 h. CPAP use of ≥4 h, ≥5 h, and ≥6 h per night was observed in 71.3%, 34.1%, and 7.8% of RCTs, respectively. Higher baseline AHI was the strongest predictor of longer CPAP use in meta-regressions (p < 0.001, β = 0.02, 95% CI 0.01–0.04). Baseline AHI was also significantly higher (40.3 ± 12.8 vs. 29.9 ± 12.6) in the ≥5 h vs. <4 h subgroup (p < 0.01, large effect size d = 0.84). A higher nightly CPAP usage was more likely in smaller (p < 0.05, d = 0.45) and single-centre trials (p < 0.05, h = 0.52). Sex distribution, age, BMI, ESS, and follow-up had no significant effect on nightly CPAP use. Conclusions: Higher baseline AHI independently predicted longer CPAP use in RCTs, while sleepiness and demographics did not. This study was registered at PROSPERO (CRD420250653394) and received no external funding. Full article

Background/Objectives: Surfactant has been delivered via less-invasive surfactant administration (LISA) in our neonatal intensive care unit (NICU) since 2020. Data have been monitored and the literature regularly reviewed to improve our LISA practice. The purpose of this project is to share the clinical practice changes made to help other NICU providers fine-tune their LISA practice. Methods: The original LISA criteria included babies with GA 27–36 6/7 w, on > 21% O₂, on continuous positive airway pressure (CPAP), pCO₂ < 70 if a blood gas was obtained, and radiographic and/or clinical evidence of respiratory distress syndrome (RDS). Current criteria include GA 25–35 6/7 w and minimum CPAP + 6. This manuscript highlights the changes made since 2023. To monitor these changes, targeted data from the entire cohort were examined before and after each change. Results: LISA was attempted on 399 babies (average (SD) GA 31.7 (2.7), birth weight 1752 (590), with a procedural success rate of 97%. Overall, 18% required intubation within 7 days after LISA. The median (IQR) for FiO₂ was 32 (28, 40) prior to LISA and 23 (21, 30) post-LISA and the hour of age of LISA was 4 (2.5, 9.9). LISA procedure success rate was increased by the use of video laryngoscopy as well as reinforcement of the use of sucrose sedation and swaddling; our first attempt success increased overall from 39% to 52%. After the introduction of a clinical RDS score (Downes), there was an expected and logical increase in the number of infants requiring intubation within 7 days of LISA indicating likely over-treatment prior to this change. After implementation of a clearly described plan for babies <28 w gestation there was a decrease in the hour of age of LISA from 3 (2.5, 4.5) to 2 (0.8, 3) h. Conclusions: It is critical to continually evaluate a new practice and identify strategic changes. We offer our changes to assist others starting or using LISA. Full article

Background: Surgical palatal techniques are established alternatives to continuous positive airway pressure (CPAP) in selective patients with obstructive sleep apnea (OSA) with retropalatal airway collapse. Anterior palatoplasty (AP) stiffens and advances the soft palate, whereas radiofrequency-assisted uvulopalatoplasty (RF-UPP) uses thermal ablation to reduce palatal tissue. This study aimed to compare the 6-month efficacy and morbidity of AP vs. RF-UPP in treating mild-to-moderate OSA. Materials and Methods: We conducted a single-center retrospective cohort study (March 2023–March 2025) of 86 adults (mean age ~42 years; 69.8% male) with mild-moderate OSA (apnea–hypopnea index [AHI] 5–30) due to palatal obstruction; 43 patients underwent AP and 43 patients underwent RF-UPP. Polysomnographic AHI, Epworth sleepiness scale (ESS), snoring severity (0–10 visual analog scale, VAS) and sleep-related quality of life (functional outcomes of sleep questionnaire, FOSQ) were analyzed at baseline and 6 months postoperatively. Postoperative pain (0–10 VAS), recovery time, and bleeding events were also assessed. Results: Baseline characteristics were similar between groups (AHI ~22 vs. 21 events/h; ESS ~11 vs. 10; snoring VAS ~8.4 vs. 8.2 in AP vs. RF-UPP, all p > 0.1). At 6 months, the AP group achieved a greater mean AHI reduction than the RF-UPP group (−13.5 ± 7.5 vs. −8.0 ± 7.2, p < 0.001), with post-treatment AHI averaging 8.5 ± 6.0 vs. 13.2 ± 6.5 events/h (AP vs. RF-UPP). AP yielded a higher surgical success rate (34/43 (79.1%) vs. 23/43 (53.5%), p = 0.012), meeting the criteria of ≥50% AHI reduction to <15; p = 0.01. Subjective outcomes improved in both groups, but AP showed greater mean reductions in ESS (−5.5 vs. −3.1 points, p = 0.001) and snoring VAS (−5.7 vs. −3.1, p = 0.002). The improvements in ESS, snoring VAS, and FOSQ scores were observed in both groups, with significantly greater gains after AP. Postoperative pain and time to resumption of normal diet were higher in the AP group. No major complications occurred in either group. Conclusions: Anterior palatoplasty demonstrated superior efficacy to RF-UPP in mild-moderate OSA at the expense of increased postoperative pain and a longer recovery period. AP may offer a greater therapeutic benefit in appropriately selected patients with palatal obstruction. Full article

Background: The landscape of paediatric oncology has undergone a remarkable transformation over recent decades. Advances in both oncological and supportive therapies have dramatically improved survival in children with haematological malignancies and solid tumours, with current survival rates exceeding 80% for many childhood cancers. However, this therapeutic success has brought with it an unexpected consequence: the intensification of treatment protocols has led to a parallel increase in life-threatening complications requiring intensive care support. Current evidence indicates that up to 40% of paediatric oncology patients will require admission to a Paediatric Intensive Care Unit (PICU) at some point during their disease trajectory. Objectives: This comprehensive review synthesises current evidence to provide an updated framework for PICU admission decision-making in oncology haematology patients. We have integrated the most recently published international guidelines, including the groundbreaking Phoenix 2024 sepsis criteria and the updated PALICC-2 2023 recommendations for paediatric acute respiratory distress syndrome. Beyond establishing admission criteria, we critically analyse the efficacy of advanced support strategies and examine emerging therapeutic approaches in this uniquely vulnerable population. Methods: Our methodology encompassed a systematic review of the literature published between 2011 and 2024, complemented by a detailed analysis of current international guidelines and expert consensus statements. We included randomised controlled trials, observational studies, meta-analyses, and consensus conference proceedings specifically addressing the intensive care management of paediatric patients with oncological or haematological conditions. Main Results: Several key findings emerge from our analysis. The Phoenix 2024 criteria represent a fundamental reconceptualisation of paediatric sepsis diagnosis, validated through an unprecedented dataset encompassing more than 3 million paediatric encounters. In the realm of respiratory support, early implementation of non-invasive ventilation (NIV) or continuous positive airway pressure (CPAP) has demonstrated remarkable efficacy, reducing the need for invasive mechanical ventilation by 45% (RR 0.45, 95% CI 0.26–0.78) when applied to appropriately selected patients. Extracorporeal membrane oxygenation (ECMO), whilst increasingly utilised, shows survival to decannulation ranging from 52% to 64%, though survival to hospital discharge remains less encouraging at 36–42%. Continuous renal replacement therapy (CRRT) has proven highly effective for tumour lysis syndrome, achieving metabolic correction in 90% of severe cases. Perhaps most promisingly, emerging biomarkers—particularly interleukin-6, interleukin-10, and procalcitonin—have substantially enhanced our ability to stratify infection risk, demonstrating sensitivity exceeding 85% for bacteraemia detection. Conclusions: The evidence unequivocally supports several core principles for optimising outcomes in this population. Early identification of deterioration through validated scoring systems enables timely intervention before irreversible organ failure develops. Prompt implementation of non-invasive respiratory support, when appropriately applied, can obviate the need for mechanical ventilation with its attendant complications. Perhaps most critically, centralisation of care in centres with dedicated expertise and comprehensive support capabilities fundamentally improves survival. These findings argue compellingly for the establishment of a formal national network of reference centres, implementing standardised protocols and structured care pathways specifically designed for critically ill paediatric oncology haematology patients. Full article

Background/Objectives: Obstructive sleep apnea (OSA) is a prevalent disorder in adults, characterized by recurrent upper airway obstruction during sleep, resulting in intermittent hypoxia, sympathetic activation, and sleep fragmentation. It is linked to significant cardiovascular, metabolic, neurocognitive, and psychosocial morbidity. There is increasing evidence that continuous positive airway pressure (CPAP) adherence remains suboptimal in many patients, and in those patients, surgery is often indicated. Methods: This protocol report presents an updated and protocol-driven surgical approach grounded in clinical evidence and experience, highlighting the role of drug-induced sleep endoscopy (DISE) and personalized multi-level interventions for adult patients with OSA. The integration of anatomical phenotyping and DISE-directed planning enables precise surgical targeting. The protocol emphasizes patient selection, individualized treatment based on obstruction patterns, and perioperative optimization. This surgical algorithm improves the success rates and long-term outcomes in patients who are intolerant of CPAP therapy. Results: A DISE-guided and multi-level surgical approach includes uvulopalatoplasty, septoplasty, tongue base reduction, palatoplasty, and maxillomandibular advancement (MMA). Preoperative assessments include BMI and the STOP-BANG and Epworth Sleepiness scales, while postoperative care emphasizes follow-up polysomnography and adjunctive therapies only when necessary. Regional experiences in Saudi Arabia and Canada underscore the importance of standardized evidence-based surgical care. Conclusions: The purpose of this article is to establish a clear protocol for managing patients diagnosed with OSA, drawing on a review of the existing literature and the insights of experienced surgeons in the field of sleep apnea, and to update current protocols with modern evidence. Full article

Background: Obstructive sleep apnea (OSA) is a highly prevalent and heterogeneous disorder associated with substantial cardiometabolic morbidity. Although continuous positive airway pressure (CPAP) remains first-line therapy, long-term effectiveness is frequently limited by suboptimal adherence. Advances in airway devices, surgical techniques, neuromodulation, and pharmacologic therapies have expanded the therapeutic landscape and created opportunities for individualized, mechanism-based treatment. Methods: We conducted a selective, narrative review with structured quantitative synthesis of randomized controlled trials, comparative cohorts, long-term follow-up studies, registries, and mechanistic investigations addressing OSA therapies beyond CPAP. Evidence spanning oral appliances, upper-airway and skeletal surgery, hypoglossal nerve stimulation, neuromuscular electrical stimulation, positional therapy, and pharmacologic interventions targeting metabolic and non-anatomical endotypes was integrated. Outcomes of interest included apnea–hypopnea index (AHI), oxygenation, blood pressure, patient-reported symptoms, durability, safety, and real-world adherence. Results: Mandibular advancement devices (MADs) consistently reduced AHI relative to placebo and produced symptom relief comparable to CPAP in mild-to-moderate OSA, largely due to superior adherence. Palatal surgery yielded meaningful short-term improvement in selected patients but demonstrated limited long-term durability. In contrast, maxillomandibular advancement (MMA) achieved the largest and most durable reductions in OSA severity, with efficacy comparable to CPAP and superior to other surgical modalities in appropriate skeletal phenotypes. Hypoglossal nerve stimulation (HNS) produced substantial, durable improvements in AHI and symptoms with high adherence, supported by randomized trials, long-term follow-up, and real-world registry data; newer bilateral and proximal stimulation systems may further broaden candidacy. Neuromuscular electrical stimulation and positional therapy provided modest, phenotype-dependent benefits, primarily as adjunctive or early-stage interventions. A major advance is the emergence of metabolic and endotype-targeted pharmacotherapy: longitudinal data demonstrate a dose-dependent relationship between weight change and OSA progression or regression, while randomized trials show that GLP-1-based therapies—particularly dual GLP-1/GIP agonism with tirzepatide—produce large, clinically meaningful reductions in AHI and cardiometabolic risk in obesity-associated OSA. Additional pharmacologic strategies targeting ventilatory loop gain and arousal threshold further support an endotype-driven treatment paradigm. Conclusions: Contemporary OSA management is shifting from a CPAP-centric model toward a precision-guided, multimodal framework that aligns therapy with dominant anatomic and physiological contributors to airway collapse. Integrating metabolic, neuromodulatory, and structural interventions—often in combination—offers the potential for durable disease control and improved patient-centered outcomes. Future priorities include head-to-head and combination trials, long-term cardiovascular outcomes, cost-effectiveness analyses, and pragmatic tools to operationalize personalized OSA therapy in routine clinical practice. Full article

Background: Obstructive sleep apnea (OSA) is a major modifiable risk factor for atrial fibrillation (AF), promoting arrhythmogenesis through intermittent hypoxia, autonomic activation, and atrial remodeling. Although continuous positive airway pressure (CPAP) effectively treats OSA, real-world evidence linking objectively measured CPAP exposure to clinically relevant AF recurrence remains limited. Aims: We aimed to evaluate the association between CPAP adherence and risk of recurrent paroxysmal AF, and to compare time to first recurrence between patients with mean nightly CPAP use ≥4 h/night versus <4 h/night. Materials and Methods: In this prospective observational cohort (2017–2024), consecutive hospitalized and outpatient adults with severe obstructive sleep apnea (OSA; apnea–hypopnea index > 30 events/h) and documented paroxysmal atrial fibrillation (AF) were enrolled. Persistent and long-standing persistent AF were excluded to ensure a homogeneous population with respect to atrial substrate. OSA was assessed using home sleep apnea testing (ResMed ApneaLink), and all patients initiated continuous positive airway pressure (CPAP) therapy (ResMed AirSense 10). Objective adherence data were obtained via the ResMed AirView telemonitoring platform. Exclusion criteria included permanent AF, prior pulmonary vein isolation, central sleep apnea, left ventricular ejection fraction < 50%, end-stage chronic kidney disease (eGFR < 15 mL/min/1.73 m² or dialysis), or inability to initiate or maintain CPAP therapy. Patients were followed for 12 months. The primary endpoint was time to first documented recurrence of paroxysmal AF (≥30 s on 12-lead electrocardiography or 24-h Holter monitoring). Progression to permanent AF, defined after unsuccessful rhythm control attempts and subsequent transition to a rate control strategy, was assessed as a secondary endpoint. Time-to-event analyses used Kaplan–Meier estimates with log-rank testing, and Cox proportional hazards regression adjusted for age, body mass index, apnea–hypopnea index, heart failure, left atrial volume index, and antiarrhythmic drug therapy. Results: The final analysis included 91 patients (mean age 62.15 ± 8.29 years; 68.13% men). Mean nightly CPAP use was ≥4 h/night in 49 patients and <4 h/night in 42 patients. During follow-up, paroxysmal AF recurrence occurred in 12/49 (24.5%) patients in the ≥4 h/night group and 16/42 (38.1%) in the <4 h/night group. Mean arrhythmia-free survival at 12 months was numerically higher in the ≥4 h/night group (11.25 vs. 10.51 months), without a statistically significant difference in Kaplan–Meier curves (log-rank p = 0.11). In multivariable Cox regression, binary adherence (≥4 h/night) was not independently associated with recurrence (HR 0.52, p = 0.13), whereas mean nightly CPAP use analyzed as a continuous variable remained independently associated with delayed recurrence (per 1-h increase: HR 0.66, 95% CI 0.48–0.91, p = 0.01). Progression to permanent AF occurred in 4/49 (10.0%) versus 9/42 (17.6%) patients, respectively (p = 0.29). Conclusions: In this real-world cohort of patients with severe OSA and paroxysmal AF, higher objectively measured CPAP exposure was independently associated with delayed AF recurrence when analyzed as a continuous variable, suggesting a graded association between objectively measured CPAP exposure and AF recurrence. Larger studies with extended follow-up and continuous rhythm monitoring are warranted to confirm long-term rhythm benefits and effects on AF progression. Full article

Obstructive sleep apnea syndrome (OSA) is increasingly recognized as a common and clinically relevant comorbidity in coronary artery disease (CAD). Epidemiological studies demonstrate that OSA is highly prevalent among patients with CAD and independently increases the risk of myocardial infarction, accelerated atherosclerosis, and recurrent adverse events. The pathophysiological mechanisms underlying this association include intermittent hypoxia, sympathetic overactivation, oxidative stress, endothelial dysfunction, systemic inflammation, metabolic dysregulation, and pro-prothrombotic changes. These processes converge to promote coronary plaque formation, instability, and ischemia. Clinical evidence indicates that OSA contributes to silent nocturnal ischemia, higher rates of acute coronary syndromes, restenosis after percutaneous coronary intervention, and worse prognosis following myocardial infarction or surgical revascularization. Continuous positive airway pressure (CPAP) therapy improves blood pressure, endothelial function, and surrogate markers of ischemia, but large randomized trials have yielded neutral results on major cardiovascular events, largely due to suboptimal adherence. However, observational studies, however, suggest improved survival in patients who are adherent to CPAP therapy. Lifestyle interventions, particularly weight reduction, remain essential adjunctive strategies. This review synthesizes current evidence, evaluates therapeutic implications, and highlights the need for systematic OSA screening in CAD populations. Future research should focus on patient phenotyping, treatment adherence, and integrated care models to improve cardiovascular outcomes. Full article