Background: The “Baveno classification” replaced the apnoea–hypopnoea index (AHI) with symptoms and comorbidities for treatment indication in obstructive sleep apnoea (OSA). This study evaluates a modified Baveno classification which adds a validated cardiovascular disease (CVD) risk score and acknowledges severe breathing disturbances.Method: OSA patients from the European Sleep Apnoea Database (ESADA) were retrospectively allocated into CVD risk groups 1–3 based on the SCORE2 risk prediction model and European Society of Cardiology guidelines. AHI ≥30 events·h⁻¹conferred strong treatment indication. When AHI was <30 events·h⁻¹, symptoms and CVD risk dictated allocation to the weak, intermediate or strong treatment indication group. Changes in Epworth Sleepiness Scale (ESS) score and office systolic blood pressure (SBP) at follow-up (12–24 months) under positive airway pressure (PAP) were assessed.Results: 8625 patients were analysed (29% female; median (interquartile range) age 56 (49–64) years and body mass index 31.9 (28.4–36.3) kg·m⁻²). Treatment indication was weak in 501 (6%), intermediate in 2085 (24%) and strong in 6039 (70%). There was a continuous increase in age, SBP, C-reactive protein and glycosylated haemoglobin from weak to strong (p<0.001). PAP prescription increased from 52% to 64% to 93% (weak to strong; p<0.001). The change in ESS score was −2, −4 and −5, respectively (p1 when AHI was <30 events·h⁻¹.Conclusion: This analysis provides supporting evidence for the key role of CVD risk assessment and severe breathing disturbances in the identification of OSA patients most likely to benefit from treatment.

Background:Programmed cell death protein 1 (PD-1)/programmed cell death protein ligand 1 (PD-L1) immune checkpoint inhibitors have been approved for monotherapy of metastatic nonsmall cell lung cancer (mNSCLC) depending on tumour cells' PD-L1 expression. Pleural effusion is common in mNSCLC. The significance of immunocytochemistry PD-L1 analysis from pleural effusion samples is unclear.Aim:The aim of the study was to analyse the sensitivity regarding immunocytochemistry PD-L1 analysis of pleural effusion in NSCLC as compared to immunohistochemistry of pleural biopsies.Patients and Methods:Fifty consecutive subjects (17 female, median age 72.5 years, seven never-smokers) were enrolled in this prospective controlled two-centre study. Inclusion criteria were pleural effusion, suspected or known lung cancer, indication for pleural puncture and thoracoscopy, and written informed consent. Immunocytochemistry and immunohistochemistry PD-L1 analyses were performed with the Dako-PDL1-IHC-22C3pharmDx assay. Analysis for sensitivity, specificity, and positive and negative predictive value was performed for PD-L1 detection from pleural effusion.Results:50 subjects underwent pleural puncture and thoracoscopy. Pathological diagnoses were lung cancer (48), lymphoma (1) and mesothelioma (1). Sensitivity, specificity, positive predictive value and negative predictive value of PD-L1-testing with expression ≥50% defined as positive were 100% (95% CI 46–100%), 63% (36–84%), 45% (18–75%) and 100% (66–100%), and with expression ≥1% defined as positive 86% (56–97%), 43% (12–80%), 75% (47–92%) and 60% (17–93%).Conclusion:PD-L1 analysis in tumour-positive pleural effusion samples shows a very high sensitivity and negative predictive value, especially regarding PD-L1 expression levels ≥50% (European Medicines Agency approval). Negative results are reliable and help in the decision against a first-line checkpoint inhibitor monotherapy. However, a 1% cut-off level (United States Food and Drug Administration approval) leads to a markedly lower negative predictive value, making other invasive procedures necessary (NCT02855281).

Introduction: Sedation during flexible bronchoscopy can be administered by a second physician, an anesthesiologist or as nurse-administered sedation (NAS). Propofol is often administered by non-anesthesiologists. It is unclear whether complications differ with various sedation protocols. Methods: We searched PubMed for clinical trials of sedation during bronchoscopy and conducted a systematic review of complications (death ≤24 h post-procedure or intensive care unit (ICU) admission/predefined cardiopulmonary escalation [CPE]). Outcomes were analyzed according to the staff administering sedation, complexity of procedure, for propofol-containing regimes, and the ASA physical status classification of the patient. Results: This analysis (120 articles, 39,475 procedures) showed a mortality rate of 0.01% for sedation bronchoscopy. ICU admission rate was 0.12%, and CPE was reported in 0.57%. Significantly higher CPE was recorded for anesthesiologists compared to NAS and second physicians (1.16% vs. 0.65% vs. 0.07%, respectively, p < 0.001) with higher ICU admission for NAS compared to anesthesiologists and second physicians (0.35% vs. 0.00% vs. 0.03%, respectively, p < 0.001). Endobronchial ultrasound did not increase complication rates. Admission to ICU and CPE remained <1% in propofol-containing regimes, although complications were slightly lower without propofol. Comparison of lower risk ASA 1–2 studies compared to studies with ASA 1–3 showed no significant difference in outcome. Conclusion: Sedation bronchoscopy is a safe procedure. The staff administering sedation may react differently to periprocedural respiratory and cardiovascular events. Propofol application is not associated with a clinically relevant increase in complication rate. There is no evidence that ASA status is a predictor of individual risk at bronchoscopy.

When to look for sleep disturbances in heart failure patients and how best to treat them: a practical and evidence-based expert opinionhttps://bit.ly/3LpCnNP