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Obstructive sleep apnea syndrome (OSAS) is associated with alterations in heart rate variability (HRV) in relation to chronic autonomic dysfunction. We tested the ability of the deep breathing technique -a simple way to evaluate HRV- to identify OSAS patients.Consecutive patients referred for suspected OSAS (without obesity, diabetes and heart diseases) were included. They underwent a measure of HRV at rest, and of heart rate (HR) oscillations during expiration vs. inspiration (DeltaHROf 31 included subjects (77% male), 14 had mild to moderate OSAS (apnea/hypopnea index, AHI median [IQR]: 18 [12]), and 17 had no OSAS. The conventional HRV analysis did not reveal any difference between the groups with vs. without OSAS. However, the DeltaHRThe deep breathing technique accurately identifies a reduction in cardiac changes in patients with mild to moderate OSAS. It could be used as a simple screening tool to select patients for polysomnography.

Sleep disorders are prevalent in patients with multiple sclerosis. In contrast, a frank increase of rapid eye movement (REM) sleep time is a rare phenomenon, mostly described in the context of REM sleep rebound (after sleep deprivation, abrupt withdrawal of antidepressants or neuroleptics, and during the first night of ventilation for severe sleep apnea), but not in link with specific brain lesions. We incidentally found an isolated, marked increase in REM sleep time (200 min, 40% of total sleep time, normative values: 18.2–20.3%) and in rapid eye movements density during REM sleep in a patient with a secondary progressive multiple sclerosis, associated with an anterior pontine demyelinating lesion on magnetic resonance imaging. This result suggests that a network blocking REM sleep in the pons has been damaged. CITATION: Zeidan S, Redolfi S, Papeix C, et al. Unexpected REM sleep excess associated with a pontine lesion in multiple sclerosis. J Clin Sleep Med. 2021;17(5):1117–1119.

Rationale: In patients with chronic obstructive pulmonary disease (COPD), increased activity of neck inspiratory muscles has been reported as a compensatory response to hyperinflation-related diaphragmatic dysfunction. The persistence of this activity during sleep could attenuate sleep-related hypoventilation and also negatively impact sleep and clinical outcomes.Objectives: To assess the persistence of neck-muscle activity during sleep in patients with COPD recovering from severe exacerbations (i.e., requiring hospitalization) and its impact on sleep quality and recurrence of exacerbations.Methods: Video polysomnography with neck-muscle EMG was performed in patients with COPD who were recovering from a severe exacerbation. The follow-up period lasted 6 months to record the next severe exacerbation.Measurements and Main Results: Twenty-nine patients were included in the study (median [25th-75th percentile] age, 71 [64-72] yr; 55% male; body mass index, 24 [21-29]; FEV1% predicted, 37 [29-45]; and BODE [body mass index, airflow obstruction, dyspnea, and exercise] index, 6 [5-7]). Twenty-six of these patients exhibited sleep-related neck-muscle activity, which was intermittent (limited to stage 3 sleep) in 17 and permanent throughout sleep in 9. α-Delta EEG activity during stage 3 sleep was observed in 87% of the patients. Compared with patients with no or intermittent neck-muscle activity, those with permanent neck-muscle activity showed more disrupted sleep, had experienced more exacerbations in the previous year, and suffered their next severe exacerbation earlier.Conclusions: Sleep-related neck-muscle activity occurs frequently in patients with COPD who are recovering from a severe exacerbation and seems to negatively affect sleep quality and prognosis; therefore, identification of this activity might improve COPD management after a severe exacerbation.

New finding What is the central question of this study? Transition to supine posture induces an inspiratory load associated with cortical activation in awake healthy subjects. Some obstructive sleep apnoea patients exhibit this cortical activity in the sitting position contributing to the arousal-dependent compensation of their upper airway abnormalities. Does a transition to the supine posture in awake obstructive sleep apnoea patients increase this cortical activity? What is the main finding and its importance? The transition to supine posture induces a reduction in the cortical activity despite evidence of an increase in genioglossus activity, suggesting that genioglossus activation is not driven by cortical activity. Abstract The anatomy and mechanical properties of the upper airway (UA) depend on posture. Lying in a supine position causes cephalad fluid shift to the neck, thus narrowing the UA and predisposing the individual to obstructive sleep apnoea (OSA). Increased UA dilator muscle activity during wakefulness prevents the UA collapse but the underlying mechanism has not yet been elucidated. In the sitting position during wakefulness, some OSA patients exhibit preinspiratory cortical activity (preinspiratory potential, PIP) probably related to UA abnormalities. The aim of this study was to investigate changes in the preinspiratory cortical activity and UA dilator muscle in OSA patients during postural challenge. An electroencephalogram was used to detect PIP, and the genioglossus electromyographic activity and ventilation were analysed in 17 awake, male OSA patients while they were sitting, just after lying down, and then in response to leg positive pressure to enhance cephalad fluid shift. The prevalence of PIP decreased from 53% (sitting) to 12% (supine) (P = 0.002) in association with increased genioglossus activity (tonic from median (25th, 75th centiles) 2.3 (1.8, 2.8)% to 3.6 (1.7, 5.0)% of voluntary deglutition, P = 0.019; phasic from 2.3 (1.9, 2.8)% to 3.7 (2.0, 6.1)%, P = 0.024), and with increased transcutaneous carbon dioxide pressure (from 43.0 (42.4, 44.2) to 44.6 (43.5, 45.2) mmHg). No change was observed during leg-positive-pressure application. Moving from the sitting position to the supine position reduces respiratory-related premotor cortical activity in awake OSA patients. The concomitant increase in genioglossus activity, therefore, is not driven by cortical respiratory activity.

Study objectives: Fluid overload shifting from the legs to the upper airway during sleep promotes obstructive sleep apnea (OSA) and interventions targeting fluid attenuate OSA. Fluid shift has been previously measured by bioelectrical impedance, a complex and time-consuming technique not applicable in the daily clinical settings. The aim of this study is to evaluate the presence of clinically detectable fluid overload and shift and its association with OSA. Methods: Patients undergoing sleep study for suspected OSA were asked to report the presence of 11 signs/symptoms associated to excessive accumulation of fluid in different parts of the body at different times of the day. Results: Among 392 patients (male: 53%, median [interquartile range] age: 56years [1], body mass index, BMI: 29kg/m2 [2]) included in the study, 135 (34%) had moderate-to-severe OSA (apnea hypopnea index, AHI ≥ 15). Daytime fluid accumulation and nocturnal fluid shift, clinically detectable by patient-reported “evening sock marks,” “heavy legs during the day,” and “morning stuffed nose,” were prevalent in the entire population (46%, 43%, and 33%, respectively). In multivariate analysis, evening sock marks was an independent correlate of having an AHI ≥ 15, together with male sex, older age, and self-reported snoring and apneas. Conclusions: Clinically detectable fluid overload and shift are prevalent in patients addressed for suspected OSA, and evening sock marks, a marker for leg swelling, is an independent correlate of moderate-to-severe OSA. This sign might contribute to OSA diagnosis and identification of patients likely to be treated by interventions targeting fluid overload and shift.

International audience; Sleep-related breathing disorders, including sleep apnea and hypoxemia during sleep, are common in pulmonary arterial hypertension, but the underlying mechanisms remain unknown. Overnight fluid shift from the legs to the upper airway and to the lungs promotes obstructive and central sleep apnea, respectively, in fluid-retaining states. The main objective was to evaluate if overnight rostral fluid shift from the legs to the upper part of the body is associated with sleep-related breathing disorders in pulmonary arterial hypertension. In a prospective study, a group of stable patients with idiopathic, heritable, related to drugs, toxins, or treated congenital heart disease pulmonary arterial hypertension underwent a polysomnography and overnight fluid shift measurement by bioelectrical impedance in the month preceding or following a one-day hospitalization according to regular pulmonary arterial hypertension follow-up schedule with a right heart catheterization. Results show that among 15 patients with pulmonary arterial hypertension (women: 87%; median (25-75th percentiles); age: 40 (32-61) years; mean pulmonary arterial pressure 56 (46-68) mmHg; pulmonary vascular resistance 8.8 (6.4-10.1) Wood units), two patients had sleep apnea and eight (53%) had hypoxemia during sleep without apnea. The overnight rostral fluid shift was 168 (118-263) mL per leg. Patients with hypoxemia during sleep had a greater fluid shift (221 (141- 361) mL) than those without hypoxemia (118 (44-178) mL, p = 0.045). In conclusion, this pilot study suggests that hypoxemia during sleep is associated with overnight rostral fluid shift in pulmonary arterial hypertension.

International audience; Sleep apnea test (SAT) is a cost-effective approach to evaluate subjects without associated comorbidities suspected for obstructive sleep apnea (OSA), a disorder particularly common in obese subjects. The association of obesity with awake hypercapnia (carbon dioxide arterial pressure, PaCO2 ≥45 mmHg) defines the obesity-hypoventilation syndrome (OHS), which in turn results in increased morbidity and mortality compared to simple OSA. Isolated hypoventilation during sleep in obese patients (obesity-related sleep hypoventilation, ORSH) is now considered as an early stage of OHS. The aim of this study was to assess the performance of SAT in diagnosing OSA and predicting the presence of ORHS among patients with grade III obesity without awake hypercapnia. Methods: Over a 14-months period, patients with grade III obesity (body mass index≥40 kg/m 2) presenting moderate-to-severe OSA (apnea-hypopnea index [AHI]≥15) upon SAT and normal awake PaCO2 at arterial blood gas analysis, systematically underwent in-lab nocturnal polysomnography combined with transcutaneous carbon dioxide pressure (PtcCO2) monitoring. Results: Among 48 patients included in the study, 16 (33%) presented an AHI

Background Obstructive sleep apnea (OSA) is highly prevalent in conditions characterized by fluid overload. Chronic venous insufficiency (CVI) is associated to fluid overload that might interfere with OSA occurrence and severity. Methods A total of 180 patients with symptomatic CVI completed the Berlin questionnaire and were assessed for the presence of symptoms and signs of OSA and fluid shift. Results According to the Berlin questionnaire, 59 patients (33%) had high risk of OSA. The predictors of having a positive Berlin questionnaire were male sex, body mass index and symptoms possibly related to fluid shift. Conclusions Patients with CVI, a disease characterized by fluid overload, present high risk of OSA, which might be related to fluid shift.

Prader–Willi syndrome (PWS) is a rare, genetic, multisymptomatic, neurodevelopmental disease commonly associated with sleep alterations, including sleep-disordered breathing and central disorders of hypersomnolence. Excessive daytime sleepiness represents the main manifestation that should be addressed by eliciting the detrimental effects on quality of life and neurocognitive function from the patients’ caregivers. Patients with PWS have impaired ventilatory control and altered pulmonary mechanics caused by hypotonia, respiratory muscle weakness, scoliosis and obesity. Consequently, respiratory abnormalities are frequent and, in most cases, severe, particularly during sleep. Adults with PWS frequently suffer from sleep apnoea syndrome, sleep hypoxemia and sleep hypoventilation. When excessive daytime sleepiness persists after adequate control of sleep-disordered breathing, a sleep study on ventilatory treatment, followed by an objective measurement of excessive daytime sleepiness, is recommended. These tests frequently identify central disorders of hypersomnolence, including narcolepsy, central hypersomnia or a borderline hypersomnolent phenotype. The use of wake-enhancing drugs (modafinil, pitolisant) is discussed in multidisciplinary expert centres for these kinds of cases to ensure the right balance between the benefits on quality of life and the risk of psychological and cardiovascular side effects.

IntroductionPreventing in-flight hypoxia in pilots is typically achieved by wearing oxygen masks. These masks must be as comfortable as possible to allow prolonged and repeated use. The consequences of mask-induced facial contact pressure have been extensively studied, but little is known about mask-induced breathing discomfort. Because breathlessness is a strong distractor and engages cerebral resources, it could negatively impact flying performances.MethodsSeventeen volunteers (age 20–32) rated respiratory discomfort while breathing with no mask and with two models of quick-donning full-face crew oxygen masks with regulators (mask A, mask B). Electroencephalographic recordings were performed to detect a putative respiratory-related cortical activation in response to inspiratory constraint (experiment 1, n=10). Oxygen consumption was measured using indirect calorimetry (experiment 2, n=10).ResultsWith mask B, mild respiratory discomfort was reported significantly more frequently than with no mask or mask A (experiment 1: median respiratory discomfort on visual analogue scale 0.9 cm (0.5–1.4), experiment 1; experiment 2: 2 cm (1.7–2.9)). Respiratory-related cortical activation was present in 1/10 subjects with no mask, 1/10 with mask A and 6/10 with mask B (significantly more frequently with mask B). Breathing pattern, sigh frequency and oxygen consumption were not different.ConclusionsIn a laboratory setting, breathing through high-end aeronautical full-face crew oxygen masks can induce mild breathing discomfort and activate respiratory-related cortical networks. Whether or not this can occur in real-life conditions and have operational consequences remains to be investigated. Meanwhile, respiratory psychometric and neuroergonomic approaches could be worth integrating to masks development and evaluation processes.

Study Objectives: In heart failure (HF), we observed two patterns of hyperpnea during Cheyne-Stokes respiration with central sleep apnea (CSR-CSA): a positive pattern where end-expiratory lung volume remains at or above functional residual capacity, and a negative pattern where it falls below functional residual capacity. We hypothesized the negative pattern is associated with worse HF. Methods: Patients with HF underwent polysomnography. During CSR-CSA, hyperpnea, apnea-hyperpnea cycle, and lung to finger circulation times (LFCT) were measured. Plasma N-terminal prohormone of brain natriuretic peptide (NT-proBNP) concentration and left ventricular ejection fraction (LVEF) were assessed. Results: Of 33 patients with CSR-CSA (31 men, mean age 68 years), 9 had a negative hyperpnea pattern. There was no difference in age, body mass index, and apnea-hypopnea index between groups. Patients with a negative pattern had longer hyperpnea time (39.5 ± 6.4 versus 25.8 ± 5.9 seconds, P < .01), longer cycle time (67.8 ± 15.9 versus 51.7 ± 9.9 seconds, P < .01), higher NT-proBNP concentrations (2740 [6769] versus 570 [864] pg/ml, P = .01), and worse New York Heart Association class (P = .02) than those with a positive pattern. LFCT and LVEF did not differ between groups. Conclusions: Patients with HF and a negative CSR-CSA pattern have evidence of worse cardiac function than those with a positive pattern. Greater positive expiratory pressure during hyperpnea is likely generated during the negative pattern and might support stroke volume in patients with worse cardiac function. Commentary: A commentary on this article appears in this issue on page 1227. Clinical Trial Registration: The trial is registered with Current Controlled Trials (www.controlled-trials.com; ISRCTN67500535) and Clinical Trials (www. clinicaltrials.gov; NCT01128816).

Introduction Both types of sleep-disordered breathing (SDB), obstructive and central sleep apnoea (OSA and CSA, respectively), are common in patients with heart failure and reduced ejection fraction (HFrEF). In such patients, SDB is associated with increased cardiovascular morbidity and mortality but it remains uncertain whether treating SDB by adaptive servo-ventilation (ASV) in such patients reduces morbidity and mortality. Aim ADVENT-HF is designed to assess the effects of treating SDB with ASV on morbidity and mortality in patients with HFrEF. Methods ADVENT-HF is a multicentre, multinational, randomized, parallel-group, open-label trial with blinded assessment of endpoints of standard medical therapy for HFrEF alone vs. with the addition of ASV in patients with HFrEF and SDB. Patients with a history of HFrEF undergo echocardiography and polysomnography. Those with a left ventricular ejection fraction ≤45% and SDB (apnoea–hypopnoea index ≥15) are eligible. SDB is stratified into OSA with ≥50% of events obstructive or CSA with >50% of events central. Those with OSA must not have excessive daytime sleepiness (Epworth score of ≤10). Patients are then randomized to receive or not receive ASV. The primary outcome is the composite of all-cause mortality, cardiovascular hospital admissions, new-onset atrial fibrillation requiring anti-coagulation but not hospitalization, and delivery of an appropriate discharge from an implantable cardioverter-defibrillator not resulting in hospitalization during a maximum follow-up time of 5 years. Conclusion The ADVENT-HF trial will help to determine whether treating SDB by ASV in patients with HFrEF improves morbidity and mortality.

International audience; To understand the mechanisms of N3 sleep interruptions in patients with sleepwalking episodes and/or sleep terrors (SW/ST), we evaluated whether autonomic reactions preceded or accompanied behavioural arousals from NREM sleep stage N3. In 20 adult patients with SW/ST and 20 matched controls without parasomnia, heart rate and pulse wave amplitude were measured beat-to-beat during the 10 beats preceding and during the 15 beats succeeding a motor arousal from N3 sleep. Respiratory rate and amplitude were measured during the same 25 successive beats. In patients with SW/ST, the N3 arousals were associated with a 33% increase in heart rate, a 57% decrease in pulse wave amplitude (indicating a major vasoconstriction), a 24% increase in respiratory rate and a doubling of respiratory amplitude. Notably, tachycardia and vasoconstriction started 4 s before motor arousals. A similar profile (tachycardia and vasoconstriction gradually increasing from the 4 s preceding arousal and post-arousal increase of respiratory amplitude, but no polypnea) was also observed, with a lower amplitude, during the less frequent 38 quiet N3 arousals in control subjects. Parasomniac arousals were associated with greater tachycardia, vasoconstriction and polypnea than quiet arousals, with the same pre-arousal gradual increases in heart rate and vasoconstriction. Autonomic arousal occurs 4 s before motor arousal from N3 sleep in patients with SW/ST (with a higher adrenergic reaction than in controls), suggesting that an alarming event during sleep (possibly a worrying sleep mentation or a local subcortical arousal) causes the motor arousal.

Backgrounds As a consequence of the increased mortality observed in the SERVE-HF study, many questions concerning the safety and rational use of ASV in other indications emerged. The aim of this study was to describe the clinical characteristics of ASV-treated patients in real-life conditions. Methods The OTRLASV-study is a prospective, 5-centre study including patients who underwent ASV-treatment for at least 1 year. Patients were consecutively included in the study during the annual visit imposed for ASV-reimbursement renewal. Results 177/214 patients were analysed (87.57% male) with a median (IQ25–75) age of 71 (65–77) years, an ASV-treatment duration of 2.88 (1.76–4.96) years, an ASV-usage of 6.52 (5.13–7.65) hours/day, and 54.8% were previously treated via continuous positive airway pressure (CPAP). The median Epworth Scale Score decreased from 10 (6–13.5) to 6 (3–9) (p p 45% in 92.7% of patients. Associated comorbidities/etiologies were cardiac in nature for 75.7% of patients (neurological for 12.4%, renal for 4.5%, opioid-treatment for 3.4%). 9.6% had idiopathic central-sleep-apnea. 6.2% of the patients were hospitalized the year preceding the study for cardiological reasons. In the 6 months preceding inclusion, night monitoring (i.e. polygraphy or oximetry during ASV usage) was performed in 34.4% of patients, 25.9% of whom required a subsequent setting change. According to multivariable, logistic regression, the variables that were independently associated with poor adherence (ASV-usage ≤4 h in duration) were TECSA group versus CSA group (p = 0.010), a higher Epworth score (p = 0.019) and lack of a night monitoring in the last 6 months (p Conclusions In real-life conditions, ASV-treatment is often associated with high cardiac comorbidities and high compliance. Future research should assess how regular night monitoring may optimize devices settings and patient management. Trial registration The OTRLASV study is registered on ClinicalTrials.gov (Identifier: NCT02429986) on 1 April 2015.

Introduction Le syndrome d’apnees obstructives du sommeil (SAOS) est considere un facteur de risque cardiovasculaire. La fermeture repetee des voies aeriennes superieures pendant le sommeil declenche des phenomenes physiopathologiques responsables d’un desequilibre sympathovagal, mediateur central des consequences cardiovasculaires. Par contre, l’effet de la CPAP sur les complications cardiovasculaires reste controverse. Une explication proposee est que l’index d’apnees-hypopnees (IAH) pourrait etre insuffisant a representer les phenomenes a l’origine des effets cardiovasculaires. Notre objectif est de tester la capacite d’une manœuvre de deep breathing (DB) a montrer une dysfonction autonomique chez des patients SAOS, en comparaison aux analyses classiques de la variabilite du rythme cardiaque (HRV). Methodes Des sujets adresses pour suspicion de SAOS, sans pathologies ni traitement alterant le systeme nerveux autonome, sont inclus prospectivement. A l’eveil en position assise, 3 minutes d’enregistrement en ventilation spontanee et 3 minutes de DB (respiration ample a 6 par minute) precedent la polysomnographie. Nous analysons la HRV lors de la respiration spontanee et la variation du rythme cardiaque lors du DB (HRDB, moyenne des 5 variations consecutives les plus amples). Resultats 16 sujets (11 hommes, âge 44 ± 10 ans, index de masse corporelle 25 ± 4 kg/m2) sont inclus. L’HRDB etait plus bas chez les SAOS (IAH 17 ± 6) que chez les controles (IAH Conclusion Le deep breathing, methode applicable en pratique clinique, permet de mettre en evidence une dysfonction autonomique non detectee par les techniques usuelles d’analyse de la variabilite cardiaque chez des patients atteints de SAOS leger a modere. En association avec la polysomnographie, le deep breathing pourrait contribuer a identifier les patients SAOS a haut risque cardiovasculaire.

Le syndrome d’apnees obstructives du sommeil (SAOS) est une affection frequente dont la somnolence diurne est le symptome principal. Des comorbidites frequemment associees au SAOS (obesite, depression, …) peuvent participer a la somnolence. La pression positive continue (PPC) demeure le traitement de reference du SAOS, mais certains patients se plaignent toutefois de somnolence sous PPC. Ces patients necessitent une prise en charge systematisee qui amenera une minorite d’entre eux a un traitement medicamenteux de la somnolence.

Objectif Pour expliquer la surmortalite cardiovasculaire associee a la Ventilation Auto-Asservie (VAA) de l’etude SERVE-HF, il a ete evoque que les reglages de la VAA auraient induit une hyperventilation. Les objectifs de cette etude sont de decrire: – les reglages de la VAA et, – la ventilation minute (VM) en fonction de l’algorithme de la VAA (VAA-volume ResMed® et VAA-debit Philips®). Methodes Etude « vie reelle » transversale multicentrique incluant des patients traites par VAA depuis plus de 1 an, aucune consigne de reglage n’etant donnee aux 8 experts investigateurs. L’analyse des donnees est realisee: – en fonction du diagnostic initial du SAS (central, obstructif, emergent sous traitement), – en fonction de 5 clusters non supervises (partitionnement en K moyennes). Resultats 177 patients sont analyses avec une mediane (IQ25–75) d’IAH initial de 50 (38-62)/h, une duree de VAA de 2.88 (1.76–4,96) ans, 61,58 % traites par VAA-volume. Seule l’analyse basee sur les 5 clusters permet de mettre en evidence des differences entre clusters et/ou type de machine: – reglage d’une pression expiratoire (EPAP) fixe plus faible dans le groupe des patients obstructifs et a fraction d’ejection ventriculaire gauche reduite, – l’usage plus frequent de l’auto-EPAP chez les patients non cardiopathes, – des VM differents entre clusters, ces differences variant en fonction du type de VAA, – un risque d’hyperventilation quel que soit le cluster et le type de VAA. Conclusion Dans l’attente des etudes en cours, il serait prudent de telesuivre les donnees de VM des patients sous VAA.

New Findings: What is the central question of this study? Moving to supine induces upper airway modifications and a fluid shift to the neck, which represent inspiratory load that predisposes to upper airway collapse.Is there cortical participation in the response to the load induced by transition to a supine posturein awake healthy subjects? What is the main finding and its importance? Moving to supine induces transient cortical activation in awake healthy subjects, with greater fluid shift, supporting possible cortical participation in the response to upper airway load induced by transition to a supine posture. Our findings open new perspectives in the understanding of the pathogenesis of obstructive sleep apnoea. Abstract: Moving from sitting upright to lying supine causes anatomical modifications and a fluid shift to the neck, which represent inspiratory loads that predispose to upper airway collapse. The pre-inspiratory potential (PIP) corresponds to the cortical activity observed during inspiratory load. In the sitting position during wakefulness, some obstructive sleep apnoea patients exhibit PIP, probably in relationship to upper airway abnormalities. The aim of this study was to investigate whether moving to the supine position induces respiratory-related cortical activation (PIP) in awake healthy subjects. The ECG was analysed to detect PIP, and EMG activity of the genioglossus muscle and ventilation were measured in the sitting position, immediately after moving to the supine position, and during application of leg positive pressure in the supine position to promote fluid shift, which was measured by bioelectrical impedance. Twenty-four subjects were included. From sitting to lying, PIP prevalence increased from 1/24 to 11/24 (P=0.002), and ventilation decreased with no change in genioglossus activity. The fluid shift from sitting to supine was higher in the subjects exhibiting PIP while supine compared with the subjects without PIP [median (25th; 75th centiles) 440(430; 520) versus 320(275; 385)ml, P=0.018], without any other differences. From before to during leg positive pressure, PIP disappeared (P=0.006). These results indicate that moving from sitting to lying induces transient respiratory-related cortical activity in awake healthy subjects with greater fluid shift, supporting possible cortical participation in the response to upper airway loading induced by moving from sitting upright to lying supine. This study offers new perspectives in the understanding of obstructive sleep apnoea pathogenesis.

We previously showed in heart failure (HF) patients that obstructive respiratory events during sleep and generation of negative intrathoracic pressure during Mueller manoeuvres, mimicking obstructive apneas, acutely reduced stroke volume (SV). We also showed that treating obstructive sleep apnea (OSA) with continuous positive airway pressure (CPAP) increased left ventricular ejection fraction over a 1-month period. We therefore hypothesized that, in HF patients, those with OSA would have greater overnight declines in SV and cardiac output (CO) than in those without sleep apnea, and that therapy of OSA using CPAP would prevent these declines.We examined overnight percent change in SV and CO in 32 HF patients with and 28 without OSA using digital photoplethysmography. Among patients with OSA, we also examined changes in SV and CO during a CPAP titration study.During the baseline polysomnogram SV and CO decreased more overnight in those with OSA than in those without sleep apnea (-12.6 ± 7.7% vs -3.2 ± 6.8%; P0.001 and -16.2 ± 9.9% vs -3.7 ± 8.3%; P0.001, respectively). Overnight changes in SV and CO correlated inversely with total apnea-hypopnea index (r = -0.551; P0.001 and r = -0.522; P0.001, respectively). In 21 patients with OSA, CPAP reduced the total apnea-hypopnea index from 37.7 ± 21.4 to 15.0 ± 16.0 (P0.001) in association with attenuation of the overnight reduction of SV (from -14.0 ± 7.9% to -3.4 ± 9.8%; P = 0.002) and CO (from -17.2 ± 9.0% to -9.7 ± 10.7%; P = 0.042).In patients with HF, coexisting OSA causes overnight declines in SV and CO that are prevented through reversal of OSA by CPAP.

Resume La prevalence des apnees obstructives du sommeil est plus elevee chez les patients presentant une retention hydrosodee, telle que l’insuffisance cardiaque chronique (ICC), que dans la population generale. Chez les patients en ICC, les apnees centrales, rares en population generale, sont egalement frequentes. Quoique la physiopathologie des apnees centrales et obstructives soit multifactorielle, ces observations suggerent que la retention des fluides contribue au developpement des deux types d’apnees chez ces patients. En particulier, l’exces de fluide accumule dans les jambes pendant le temps passe en position verticale peut etre redistribue selon un axe caudorostral en position allongee, tout au long de la nuit. Une partie de ces fluides peut atteindre le cou, augmentant la pression tissulaire autour des voies aeriennes superieures et predisposant aux apnees obstructives. Chez les patients en ICC, les fluides peuvent egalement s’accumuler au niveau des poumons entrainant une hyperventilation a l’origine d’une baisse de la PaCO 2 au-dessous du seuil apneique, conduisant a l’apparition d’apnees centrales. Cet article a pour but de faire le point sur les differentes etudes ayant explore le role du transfert de fluide dans la genese des apnees tant obstructives que centrales.

Study Objectives Excessive sleepiness is a common symptom in Prader–Willi syndrome (PWS), and it negatively impacts the quality of life. Obstructive sleep apnea and narcolepsy phenotypes have been reported in PWS. We characterized sleep disorders in a large cohort of adults with PWS. Methods All consecutive patients with genetically confirmed PWS unselected for sleep-related symptoms, underwent a clinical interview, polysomnography, and multiple sleep latency tests (MSLT, n = 60), followed by long-term (24 hours) polysomnography (n = 22/60). Results Among 60 adults evaluated (57% female, aged 25 ± 10 years, body mass index: 39 ± 12 kg/m2), 67% reported excessive sleepiness. According to the sleep study results, 43% had a previously unrecognized hypersomnia disorder, 15% had an isolated sleep breathing disorder, 12% had combined hypersomnia disorder and untreated breathing sleep disorder, and only 30% had normal sleep. Isolated hypersomnia disorder included narcolepsy in 35% (type 1, n = 1, and type 2, n = 8), hypersomnia in 12% (total sleep time >11 hours, n = 2, and MSLT 8 minutes, n = 10, and 8 minutes < MSLT < 10 minutes, n = 4). Sleep breathing disorders, isolated and combined, included obstructive sleep apnea (n = 14, already treated in seven), sleep hypoxemia (n = 1) and previously undiagnosed hypoventilation (n = 5). Modafinil was taken by 16 patients (well tolerated in 10), resulting in improved sleepiness over a mean 5-year follow-up period. Conclusion Sleepiness affects more than half of adult patients with PWS, with a variety of hypersomnia disorder (narcolepsy, hypersomnia, and borderline phenotypes) and breathing sleep disorders. Earlier diagnosis and management of sleep disorders may improve sleepiness, cognition, and behavior in these patients.

International audience; Sleep apnea is a common condition associated with increased morbidity and mortality. Continuous positive airway pressure and oral appliances are efficient for treating sleep apnea; however, they are often poorly tolerated. Therefore, alternative therapies are needed. Overnight rostral fluid shift has been implicated in the pathogenesis of sleep apnea, particularly in conditions associated with fluid overload. Fluid shift predisposes to both obstructive and central sleep apnea, with the type of sleep apnea being related to whether the fluid shifts from the legs into the neck or chest, respectively. The amount of fluid that shifts from the legs to the upper part of the body at night is correlated with the severity of sleep apnea. As a result of this observation, it has been suggested that the prevention of overnight fluid shift may reduce sleep apnea severity. It has recently been shown that interventions targeting fluid overload and daytime fluid accumulation in the legs consistently attenuate nocturnal fluid shift and sleep apnea, as greater reductions in fluid shift are correlated with greater reductions in sleep apnea severity. This review will focus on interventions that counteract fluid shift, such as diuretics, ultrafiltration/dialysis, physical activity, compression stockings and salt/fluid restriction, which have been shown to have efficacy in reducing sleep apnea severity.

Objectives To determine the frequency of sleep breathing disorders in multiple systemic atrophy (MSA, combining Parkinsonism, cerebellar syndrome, and dysautonomia) and evaluate the benefit/tolerance of various modes of ventilation. Methods We retrospectively analyzed 45 patients with MSA having undergone a videopolysomnography. Their sleep characteristics were compared to those of 45 patients with Parkinson's disease and 45 healthy controls, matched for age and sex. Patients with MSA received fixed continuous positive airway pressure (CPAP) when stridor was isolated, auto-adjusting CPAP when it was combined with obstructive sleep apnea, and adaptive servo-ventilation (ASV) when combined with central sleep apnea. Results Higher periodic leg movements index and more frequent REM sleep behavior disorder were observed in MSA patients, compared to patients with Parkinson's disease and healthy controls. In MSA, 28/45 (62.2%) patients had sleep breathing disorders, including (overlapping samples) stridor (n = 17, 38%), obstructive sleep apnea (n = 14, 31%), central sleep apnea (n = 4, 9%), and ataxic breathing (n = 1). Except for three initial refusals and two yet untreated patients, fixed CPAP (n = 9), auto-adjusting CPAP (n = 8) and ASV (n = 2) were well-tolerated (limited leaks and good compliance) and successfully controlled stridor plus sleep apnea. Treated patients had survival times similar to those of patients without any sleep breathing disorder. Conclusion In this small group, tailored management of stridor in MSA as an independent issue or combined with obstructive and central sleep apnea, yields a survival similar to survival in patients without sleep breathing disorders.

Resume En 2012, la Sleep Apnea Definitions Task Force, groupe appartenant a l’American Academy of Sleep Medicine, editait de nouvelles regles pour scorer les evenements respiratoires au cours du sommeil. Ces regles disponibles en ligne sont regulierement mises a jour, les dernieres modifications datant de septembre 2013. Leur but est de clarifier et de simplifier les regles anterieurement editees, d’evaluer et d’integrer les nouvelles technologies d’enregistrement pertinentes, et d’aboutir a une meilleure concordance entre regles appliquees a l’adulte et a l’enfant. En resume, chez l’adulte, il est recommande de scorer : une apnee s’il existe une chute ≥ 90 % du flux pendant au moins 10 secondes, enregistree preferentiellement par un capteur oronasal thermique, ou a partir du signal de flux de l’appareil de ventilation ; une hypopnee s’il existe une chute ≥ 30 % du flux pendant au moins 10 secondes, associee a une diminution de la saturation ≥ 3 %, ou a un eveil, enregistree preferentiellement par un capteur de pression nasale, ou a partir du signal de flux de l’appareil de ventilation ; une respiration de Cheyne-Stokes s’il existe au moins 3 apnees et/ou hypopnees consecutives separees par une variation crescendo-decrescendo de l’amplitude de la respiration avec une longueur de cycle ≥ 40 s et un index d’apnees/hypopnees centrales ≥ 5/h, pendant au moins 2 heures d’enregistrement ; une hypoventilation si la PCO 2 > 55 mmHg ou s’il existe une augmentation de la PCO 2 d’au moins 10 mmHg d’une valeur excedant 50 mmHg, pendant au moins 10 minutes.

Introduction: Both types of sleep-disordered breathing (SDB), obstructive and central sleep apnoea (OSA and CSA, respectively), are common in patients with heart failure and reduced ejection fraction (HFrEF). In such patients, SDB is associated with increased cardiovascular morbidity and mortality but it remains uncertain whether treating SDB by adaptive servo-ventilation (ASV) in such patients reduces morbidity and mortality. Aim: ADVENT-HF is designed to assess the effects of treating SDB with ASV on morbidity and mortality in patients with HFrEF. Methods: ADVENT-HF is a multicentre, multinational, randomized, parallel-group, open-label trial with blinded assessment of endpoints of standard medical therapy for HFrEF alone vs. with the addition of ASV in patients with HFrEF and SDB. Patients with a history of HFrEF undergo echocardiography and polysomnography. Those with a left ventricular ejection fraction ≤45% and SDB (apnoea–hypopnoea index ≥15) are eligible. SDB is stratified into OSA with ≥50% of events obstructive or CSA with >50% of events central. Those with OSA must not have excessive daytime sleepiness (Epworth score of ≤10). Patients are then randomized to receive or not receive ASV. The primary outcome is the composite of all-cause mortality, cardiovascular hospital admissions, new-onset atrial fibrillation requiring anti-coagulation but not hospitalization, and delivery of an appropriate discharge from an implantable cardioverter-defibrillator not resulting in hospitalization during a maximum follow-up time of 5 years. Conclusion: The ADVENT-HF trial will help to determine whether treating SDB by ASV in patients with HFrEF improves morbidity and mortality.

International audience; In humans, inspiratory constraints engage cortical networks involving the supplementary motor area. Functional magnetic resonance imaging (fMRI) shows that the spread and intensity of the corresponding respiratory-related cortical activation dramatically decrease when a discrete load becomes sustained. This has been interpreted as reflecting motor cortical reorganization and automatisation, but could proceed from sensory and/or affective habituation. To corroborate the existence of motor reorganization between single-breath and sustained inspiratory loading (namely changes in motor neurones recruitment), we conducted a diaphragm twitch interpolation study based on the hypothesis that motor reorganization should result in changes in the twitch interpolation slope. Fourteen healthy subjects (age: 21–40 years) were studied. Bilateral phrenic stimulation was delivered at rest, upon prepared and targeted voluntary inspiratory efforts (“vol”), upon unprepared inspiratory efforts against a single-breath inspiratory threshold load (“single-breath”), and upon sustained inspiratory efforts against the same type of load (“continuous”). The slope of the relationship between diaphragm twitch transdiaphragmatic pressure and the underlying transdiaphragmatic pressure was −1.1 ± 0.2 during “vol,” −1.5 ± 0.7 during “single-breath,” and −0.6 ± 0.4 during “continuous” (all slopes expressed in percent of baseline.percent of baseline−1) all comparisons significant at the 5% level. The contribution of the diaphragm to inspiration, as assessed by the gastric pressure to transdiaphragmatic pressure ratio, was 31 ± 17% during “vol,” 22 ± 16% during “single-breath” (p = 0.13), and 19 ± 9% during “continuous” (p = 0.0015 vs. “vol”). This study shows that the relationship between the amplitude of the transdiaphragmatic pressure produced by a diaphragm twitch and its counterpart produced by the underlying diaphragm contraction is not unequivocal. If twitch interpolation is interpreted as reflecting motoneuron recruitment, this study supports motor reorganization compatible with “diaphragm sparing” when an inspiratory threshold load becomes sustained.

Objectif La prevalence du syndrome d’apnees obstructives du sommeil (SAOS) est elevee dans des pathologies associees a retention hydrique. Effectivement le deplacement de fluide des membres inferieurs vers la region cervicale au cours du sommeil favorise la survenue d’apnees obstructives. L’insuffisance veineuse est associee a retention hydrique et pourrait donc etre associee aussi au SAOS. L’objective de l’etude est d’evaluer la prevalence de patients a risque de SAOS en cas d’insuffisance veineuse symptomatique. Methodes Enquete multicentrique, par questionnaire electronique comprenant le score de Berlin (+ : risque haut, − risque faible de SAOS), les symptomes associes au SAOS et a un exces de fluide dans differentes parties du corps en differents moments du jour chez de patients consultant un medecin vasculaire pour une insuffisance veineuse symptomatique (classe CEAP ≥ 2) sans SAOS connu. Resultats Sur 12 semaines en 2016 180 patients ont etes inclus (37 % hommes, âge m ± SD 61 ± 15 ans, IMC 29 ± 4 kg/m 2 , CEAP 2 48 %), 33 % (IC95 % : 26–40 %) avait un Berlin+. Les facteurs de risque associes independamment a un Berlin+ etaient sexe masculin, âge, IMC, classe CEAP et symptome « traces des chaussettes le soir ». Conclusion Le risque d’avoir un SAOS evalue par score de Berlin est eleve dans l’insuffisance veineuse symptomatique et est en relation avec, autre que les facteurs classiquement associes au SAOS, la gravite de l’insuffisance veineuse et la retention hydrique.

Objectif Nous avons precedemment montre, chez des patients en position assise ayant un syndrome d’apnees obstructives du sommeil, la presence de potentiels pre-moteurs inspiratoires (PPI) sur l’electroencephalogramme d’eveil, traduisant l’existence d’une compensation corticale de la charge mecanique situee au niveau de leurs voies aeriennes superieures (VAS). Il a ete montre que le deplacement des fluides des membres inferieurs vers la region cervicale (DF) augmente la charge mecanique au niveau des VAS et favorise la survenue d’apnees obstructives. Notre objectif est d’evaluer si le DF entraine l’apparition d’une compensation corticale. Methodes Nous avons induit un DF par le passage de la position assise a allongee puis par l’application d’un pantalon anti-gravite (PAG) chez des sujets sains, a l’eveil, et recherche l’apparition d’un PPI. Resultats Nous avons inclus 12 hommes sains (âge median 27 ± 6 ans ; IMC 21,7 ± 4,6 kg/m2). Le passage de la position assise a la position allongee a provoque un DF de 410 ± 140 mL et le PAG de 95 ± 143 mL Un PPI etait retrouve chez 1 sujet en position assise, chez 5 sujets en position allongee et chez 0 sujet apres application du PAG. Les sujets ayant un PPI en position allongee avait un DF plus important lors du passage de la position assise a allongee que les sujets sans PPI en position allongee (440 ± 90 vs 320 ± 45 mL, p = 0,02), sans difference d’âge et d’IMC. Conclusion Le passage de la position assise a allongee entraine un DF et est associe a l’apparition d’une compensation corticale transitoire chez le sujet sain a l’eveil.

Fluid accumulation in the legs and its overnight redistribution into the neck appears to play a causative role in obstructive sleep apnea (OSA) in sedentary men. Chronic venous insufficiency (CVI) promotes fluid accumulation in the legs that can be counteracted by compression stockings.To test the hypotheses that, in nonobese subjects with CVI and OSA, wearing compression stockings during the day will attenuate OSA by reducing the amount of fluid displaced into the neck overnight.Nonobese subjects with CVI and OSA were randomly assigned to 1 week of wearing compression stockings or to a 1-week control period without compression stockings, after which they crossed over to the other arm. Polysomnography and measurement of overnight changes in leg fluid volume and neck circumference were performed at baseline and at the end of compression stockings and control periods.Twelve subjects participated. Compared with the end of the control period, at the end of the compression stockings period there was a 62% reduction in the overnight leg fluid volume change (P = 0.001) and a 60% reduction in the overnight neck circumference increase (P = 0.001) in association with a 36% reduction in the number of apneas and hypopneas per hour of sleep (from 48.4 ± 26.9 to 31.3 ± 20.2, P = 0.002).Redistribution of fluid from the legs into the neck at night contributes to the pathogenesis of OSA in subjects with CVI. Prevention of fluid accumulation in the legs during the day, and its nocturnal displacement into the neck, attenuates OSA in such subjects.

The amount of fluid displaced overnight from the legs into the neck as a consequence of lying recumbent correlates with the number of apneas and hypopneas per hour of sleep (AHI). Sedentary living promotes dependent fluid accumulation in the legs that can be counteracted by venous compression of the legs (compression stockings). We hypothesized that, in non-obese sedentary men with obstructive sleep apnea (OSA), wearing compression stockings during daytime will reduce the AHI by reducing the amount of fluid available for the displacement into the neck overnight. Polysomnography and measurement of overnight changes in leg fluid volume and neck circumference were performed at baseline and after one day of legs venous compression. The median AHI decreased from 30.9 (interquartile range 19.6–60.4) to 23.4 (12.9–31.8) (P = 0.016) in association with a median 40% reduction in the change in leg fluid volume (P = 0.016) and a median 42% reduction in the increase in neck circumference (P = 0.016). These results provide proof-of-principle that overnight fluid displacement into the neck plays a causative role in OSA.

Introduction Peu de donnees sur l’usage de la Ventilation Auto-Asservie (VAA) en vie reelle existent. Dans ce contexte post SERVE-HF, les cliniciens sont dans l’attente de nouvelles donnees. Le but de cette etude est de decrire les caracteristiques cliniques des patients traites actuellement en conditions de vie reelle par VAA. Methodes L’etude OTRLASV (NCT02429986) est une etude prospective observationnelle multicentrique concernant des patients traites par VAA depuis au moins 1 an. Les donnees sont collectees consecutivement lors des consultations annuelles imposees pour le renouvellement de la prise en charge de la VAA, chacun des 5 centres restant ouvert 14 mois (1ere inclusion en mars 2015 pour le premier centre, derniere inclusion en decembre 2016 pour le dernier centre, 11 patients de phenotype SERVE-HF sont exclus). Resultats Au total, 177 patients sont inclus dans l’analyse finale (87,57 % d’hommes avec une mediane (IQ 25–75) d’âge de 71 (65–77) ans, une duree de traitement par VAA de 2,88 (1,76–4,96) annees, une utilisation de la VAA de 6,52 (5,1–7,6) heures/jour, 54,8 % des patients ayant ete prealablement traites par CPAP). La mediane de score d’Epworth est passee de 10 (6–13,5) a 6 (3–9) sous VAA (p 45 % dans 92,6 % des cas), neurologique dans 12,4 % des cas, renale dans 4,5 % des cas, 3,4 % des patients consomment des opiaces (14,12 % avec deux comorbidites). Au total, 13,5 % des patients presentaient une forme centrale idiopathique. Seulement 6,21 % des patients sont hospitalises pour raison cardiologique l’annee precedant leur inclusion. Le delai entre la derniere consultation cardiologique et l’inclusion dans l’etude est de 183 (70–365) jours, 97,97 % des patients ont beneficie d’une echocardiographie avec un delai de 263 (116–529) jours avant inclusion dans l’etude. Dans les 6 derniers mois precedant l’inclusion, 31 % des patients ont beneficie d’une polygraphie (PV) ou d’une oxymetrie (oxy) ayant conduit a une modification des reglages (9 patients) ou de l’interface (7 patients). Ce suivi cardiologique ou PV/oxy ne dependant pas de la date de mise en place de la VAA, il est peu probable qu’il ait pu etre influence par les resultats de l’etude SERVE-HF. Conclusion En conditions de vie reelle, a la difference des derniers essais randomises publies, la VAA est associee a une tres bonne observance et un suivi PV/oxy frequent.

The cause of increased pharyngeal collapsibility in patients with obstructive sleep apnea is incompletely understood. In awake healthy subjects, we showed that fluid displacement from the legs into the neck induced by lower body positive pressure reduces upper airway size and increases its collapsibility. Prolonged sitting leads to dependent fluid accumulation in the legs.To test the hypotheses that the apnea-hypopnea index (AHI) during sleep will be related to the amount of fluid spontaneously displaced from the legs overnight, and that this will, in turn, be related to the time spent sitting the previous day.In 23 nonobese healthy men referred for sleep studies for suspected obstructive sleep apnea, we assessed the changes in leg fluid volume and in neck circumference from the beginning to the end of the night, and the time spent sitting during the previous day.The overnight change in leg fluid volume correlated strongly with the AHI (r = -0.773, P0.001), the change in neck circumference (r = -0.792, P0.001), and the time spent sitting (r = -0.588, P = 0.003). Multivariate analysis showed that the only significant independent correlates of the AHI were the overnight changes in leg fluid volume and neck circumference, which together explained 68% of the variability in the AHI among subjects.These novel findings suggest that overnight rostral fluid displacement from the legs, related to prolonged sitting, may play a previously unrecognized role in the pathogenesis of obstructive sleep apnea in nonobese men that is independent of body weight.

Summary Aim: Obstructive sleep apnoeas generate an intense afferent traffic leading to arousal and apnoea termination. Yet a decrease in the sensitivity of the afferents has been described in patients with obstructive sleep apnoea, and could be a determinant of disease severity. How mechanical changes within the respiratory system are processed in the brain can be studied through the analysis of airway occlusion-related respiratory-related evoked potentials. Respiratory-related evoked potentials have been found altered during sleep in mild and moderate obstructive sleep apnoea syndrome, with contradictory results during wake. We hypothesized that respiratory-related evoked potentials’ alterations during wake, if indeed a feature of the obstructive sleep apnoea syndrome, should be present in untreated severe patients. Methods: Ten untreated patients with severe obstructive sleep apnoea syndrome and eight matched controls were studied. Respiratory-related evoked potentials were recorded in Cz-C3 and Cz-C4, and described in terms of the amplitudes and latencies of their components P1, N1, P2 and N2. Results: Components amplitudes were similar in both groups. There was no significant difference in P1 latencies. This was also the case for N1 in Cz-C3. In contrast, N1 latencies in Cz-C4 were significantly longer in patients with obstructive sleep apnoea syndrome [median 98 ms (interquartile range 16·00) versus 79·5 ms (5·98), P = 0·015]. P2 and N2 were also significantly delayed, on both sides. Conclusions: The cortical processing of airway occlusion-related afferents seems abnormal in untreated patients with severe obstructive sleep apnoea syndrome. This could be either a severity marker and/or an aggravating factor.

Background: No consistent data are available regarding the effect of inhaled corticosteroids (ICS) in α1-antitrypsin-deficiency (AATD)-related COPD. Recent data report inflammatory effects of the polymers of α1-antitrypsin on the peripheral lung. Objectives: The aim of this study was to assess the effectiveness of an extra-fine ICS, hydrofluoroalkane-134a beclometasone dipropionate (HFA-BDP) with a mass median aerodynamic diameter of 1.1 µm, on lung function and exercise tolerance in COPD patients with AATD when added to long-acting bronchodilators (LABAs). Methods: After a 1-week washout, 8 steroid-naïve COPD patients with AATD (ZZ genotype), within a double-blind randomized cross-over study, were assigned to one of the following 16-week treatments: (1) HFA-BDP 400 µg b.i.d., salmeterol 50 µg b.i.d. and oxitropium bromide 200 µg t.i.d. or (2) placebo, salmeterol 50 µg b.i.d. and oxitropium bromide 200 µg t.i.d; after a 2-week washout period they received the other treatment. In weeks 1, 17, 19 and 35, patients took a spirometry assessment (breathing air and heliox) and a shuttle walking test (SWT) with dyspnea assessed by the modified Borg scale. Results: Significant differences in improvement were found in FEV1, FVC, IC, distance covered and dyspnea perceived during SWT between the 2 treatments and baseline values (p < 0.05; Friedman’s test). However, further analysis showed that only the LABAs + ICS condition showed significant increases in the FEV1, FVC, IC, ΔMEF50% and distance covered during SWT along with a reduction in maximum isostep exertional dyspnea (p < 0.05; Wilcoxon test). A greater distance was walked at the end of the SWT with LABA + ICS than LABAs alone (301 ± 105 vs. 270 ± 112 m; p < 0.05). Conclusions: In AATD-related COPD patients (ZZ genotype) the addition of extra-fine ICS to LABAs decreases airway narrowing, mostly in the small airways, further reducing dynamic hyperinflation with a marked improvement in exercise tolerance and dyspnea, suggesting that a peripheral inflammatory process contributes to airflow obstruction in these patients.

Faced with mechanical inspiratory loading, awake animals and anaesthetized humans develop alveolar hypoventilation, whereas awake humans do defend ventilation. This points to a suprapontine compensatory mechanism instead of or in addition to the ‘traditional’ brainstem respiratory regulation. This study assesses the role of the cortical pre-motor representation of inspiratory muscles in this behaviour. Ten healthy subjects (age 19–34 years, three men) were studied during quiet breathing, CO2-stimulated breathing, inspiratory resistive loading, inspiratory threshold loading, and during self-paced voluntary sniffs. Pre-triggered ensemble averaging of Cz EEG epochs starting 2.5 s before the onset of inspiration was used to look for pre-motor activity. Pre-motor potentials were present during voluntary sniffs in all subjects (average latency (±s.d.): 1325 ± 521 ms), but also during inspiratory threshold loading (1427 ± 537 ms) and during inspiratory resistive loading (1109 ± 465 ms). Pre-motor potentials were systematically followed by motor potentials during inspiratory loading. Pre-motor potentials were lacking during quiet breathing (except in one case) and during CO2-stimulated breathing (except in two cases). The same pattern was observed during repeated experiments at an interval of several weeks in a subset of three subjects. The behavioural component of inspiratory loading compensation in awake humans could thus depend on higher cortical motor areas. Demonstrating a similar role of the cerebral cortex in the compensation of disease-related inspiratory loads (e.g. asthma attacks) would have important pathophysiological implications: it could for example contribute to explain why sleep is both altered and deleterious in such situations.

Cortical potentials evoked by mid-inspiratory occlusion arise from numerous receptors, many of which are probably within the upper airway. Their precise nature is not known. The aim of the current study was to improve knowledge of this by studying the effects of topical upper airway anaesthesia on respiratory-related evoked potentials. Respiratory-related evoked potentials were described through the averaging of electroencephalogram (EEG) epochs following mid-inspiratory occlusions (C 3 –C Z ; C 4 –C Z ). A total of 21 healthy volunteers (13 male, aged 22–52 yrs) were studied during mouth breathing, before and after topical upper airway anaesthesia (lidocaine). Moreover, 15 subjects were studied during nose breathing with and without anaesthesia. Six subjects were studied whilst inhaling L-menthol. Typical potentials were present in all the subjects, their components featuring normal amplitudes and latencies. The route of breathing and upper airway anaesthesia did not modify the EEG responses to inspiratory occlusions, qualitatively or quantitatively, during mouth or nose breathing. L-menthol had no effect. Upper airway receptors sensitive to topical anaesthesia are unlikely to contribute significantly to mid-inspiratory occlusion-evoked potentials. On the contrary, deeper receptors, such as joint and muscle receptors, could contribute dominantly to these potentials.

Introduction Le deplacement rostral nocturne de fluide favorise le syndrome d’apnees obstructives du sommeil (SAOS). Les interventions capables de l’attenuer reduisent la gravite du SAOS. Actuellement, ce deplacement est mesure par bio-impedancemetrie, technique complexe et chronophage. Reperer cliniquement ce deplacement pourrait orienter vers des traitements alternatifs a la pression positive continue (PPC). L’objectif de l’etude est d’evaluer la presence des manifestations cliniques du deplacement rostral nocturne de fluide dans le SAOS. Methodes Nous avons developpe un questionnaire pour tester la presence de 11 signes/symptomes causes par l’accumulation de liquide dans le bas du corps a la fin de la journee et dans la partie superieure du corps pendant la nuit et le matin. Tous les patients enregistres dans notre service pour suspicion de SAOS entre mai 2015 et janvier 2016 ont complete ce questionnaire « fluide ». Nous avons inclus dans cette etude les patients non obeses avec SAOS leger a severe. Resultats Parmi les 109 patients, 63 avec SAOS leger (index d’apnees-hypopnees entre 5 et 15) et 46 patients avec SAOS modere ou severe (index d’apnees-hypopnees > 30) apparies sur l’âge, le sexe et l’indice de masse corporel (59 ans, 56 % d’hommes, 26 kg/m2 respectivement) ont repondu au questionnaire. Nous avons retrouve chez 30 % ou plus de l’ensemble des patients, 3 des 11 signes/symptomes du questionnaire « fluide » : « marque des chaussettes le soir », « sensation de jambes lourdes » et « nez obstrue le matin ». Deux symptomes ou signes etaient plus frequents dans le groupe SAOS modere/severe par rapport au groupe SAOS leger : « necessite de dormir avec 2 coussins » et « nez obstrue le matin » (16 % vs. 2 %, p = 0,007 et 46 % vs. 24 %, p = 0,019). Conclusion Nous retrouvons des signes ou symptomes compatibles avec un deplacement rostral nocturne de fluide chez les patients SAOS non obeses. La frequence de certains de ces symptomes augmente avec la gravite du SAOS. La recherche de ces signes/symptomes evocateurs d’un deplacement rostral nocturne de fluide dans la prise en charge du SAOS pourrait conduire a la mise en route de traitement alternatif a la ventilation par PPC chez les patients SAOS non obeses.

Repeated inspiratory occlusions in humans elicit respiratory-related cortical potentials, the respiratory counterpart of somatosensory-evoked potentials. These potentials comprise early components (stimulus detection) and late components (cognitive processing). They are considered as the summation of several afferent activities from various part of the respiratory system. This study assesses the role of the upper airway as a determinant of the early and late components of the potentials, taking advantage of the presence of a tracheotomy in patients totally or partially deafferented. Eight patients who could breathe either through the mouth or through a tracheotomy orifice (whole upper airway bypassed) were studied (4 quadriplegic patients with phrenic pacing, 4 patients with various sources of inspiratory pump dysfunction). Respiratory-related evoked potentials were recorded in CZ-C3 and CZ-C4. They were consistently present after mouth occlusions, with a first positive P1 and a first negative N1 components of normal latencies (P1: 40.4 ± 6.1 ms in CZ-C3 and 47.6 ± 7.6 ms in CZ-C4; N1: 84.4 ± 27.1 ms in CZ-C3 and 90.2 ± 17.4 ms in CZ-C4) and amplitudes. Tracheal occlusions did not evoke any cortical activity. Therefore, in patients with inspiratory pump dysfunction, the activation of upper airway afferents is sufficient to produce the early components of the respiratory-related evoked cortical potentials. Per contra, in this setting, pulmonary afferents do not suffice to evoke these components.

Objectif La ventilation auto asservie (VAA) a ete concue pour traiter les troubles respiratoires du sommeil chez les patients avec insuffisance cardiaque (IC). Malgre le fait qu’une utilisation reguliere de la VAA soit associee a une amelioration des symptomes et de la qualite de vie, l’observance reste problematique. Nous avons evalue l’observance a la VAA chez des patients avec IC et apnees du sommeil centrales (ACS) ou obstructives (AOS) dans l’etude ADVENT-HF, afin de determiner les facteurs predictifs de l’observance a court et long terme. Methodes Patients inclus et mis sous VAA entre septembre 2010 et avril 2017. La moyenne d’heures d’utilisation/nuit de la VAA a ete calculee a 1 et 12 mois de la randomisation et a ete comparee entre les groupes ACS et AOS. Resultats L’observance a 1 et 12 mois etait de 4,6 ± 2,1 et 4,0 ± 2,5 h/nuit (p Conclusion Dans l’etude Advent-HF, l’observance est bonne a 1 mois et a 12 mois, elle est stable dans le groupe ACS et baisse dans le groupe AOS. L’observance a 1 mois est correlee a l’amelioration de l’efficacite du sommeil et elle predit l’observance a 12 mois.

Objectif Les troubles respiratoires du sommeil (TRS) sont frequents dans l’obesite morbide (indice de masse corporelle, IMC ≥ 40 kg/m2), notamment le syndrome d’apnees obstructives du sommeil (SAOS) qui en presence d’hypoventilation diurne rentre dans le cadre du syndrome d’obesite-hypoventilation (SOH). Ces TRS et le SOH en particulier sont associes a une morbi-mortalite augmentee. Une prise en charge precoce et optimale est donc necessaire. L’objective de l’etude est d’identifier la meilleure approche diagnostique. Methodes Les patients hospitalises pour plus de 24 h dans le service de nutrition de notre hopital pour la prise en charge de leur obesite ont une polygraphie ventilatoire (PV) et des gaz du sang. Les patients avec obesite morbide presentant un index de desaturation > 30/h sans hypoventilation diurne ont ete enregistres dans le service du SOMMEIL par polysomnographie avec mesure du dioxyde de carbone transcutanee (PtcCO2). Resultats Entre mai et septembre 2017, nous avons inclus 14 patients (3 hommes, âge m ± SD 49 ± 15 ans, IMC 45 ± 4 kg/m2, index des apnees/hypopnees, IAH a la PV 43 ± 17/h). La PSG avec PtcCO2 n’a confirme la presence d’un SAOS severe (IAH > 30) que chez 7 patients (50 %) et a en revanche identifie une hypoventilation nocturne chez 3 (21 %). Conclusion Au cours de l’obesite morbide une simple evaluation par PV ne semble pas etre appropriee pour un diagnostic correct des TRS. Une etude diagnostique plus approfondie semble donc etre utile pour une prise en charge optimale. L’etude merite d’etre poursuivie pour etre confirmee sur un plus grand nombre de patients.

Objectif Determiner la frequence des troubles respiratoires du sommeil (TRS) dans l’atrophie multisystematisee (AMS) et evaluer le benefice/tolerance des divers modes de ventilation. Methodes Nous avons analyse retrospectivement les caracteristiques du sommeil chez 45 patients atteints d’AMS ayant eu une videopolysomnographie, et les comparees a celles de 45 patients parkinsoniens et 45 temoins sains. Les patients AMS ont recu une pression positive continue (PPC) fixe lorsque le stridor a ete isole, une PPC autopilotee (autoPPC) s’il a ete associe a un syndrome d’apnees obstructives du sommeil (SAOS) et une ventilation auto-asservie (VAA) ou une PPC fixe s’il est combine a un syndrome d’apnees centrales du sommeil (SACS). Resultats L’augmentation de la latence d’endormissement, du pourcentage du stade N2, de l’index de mouvements periodiques des jambes, du trouble comportemental en sommeil paradoxal et la diminution du temps du sommeil total et du pourcentage de sommeil paradoxal ont ete observes chez les patients AMS par rapport aux autres groupes. Dans l’AMS, 62,2 % des patients avaient des TRS : stridor (n = 16), SAOS (n = 14), SACS (n = 4) et respiration ataxique (n = 1). A l’exception de 5 patients (trois refus initiaux et deux en cours d’appareillage), la PPC fixe (n = 9), l’autoPPC (n = 8) et la VAA (n = 2) etaient bien toleres et le stridor a ete bien controle, ainsi que les apnees. Leur survie a ete comparable a celle des patients sans TRS. Conclusion Les TRS associes a l’AMS sont multiples. Les differents traitements par pression positive sont efficaces et bien toleres par les patients.