The objective of this randomized controlled trial was to assess the additional effect of a chest-worn sleep position trainer (SPT) in patients with residual supine-dependent obstructive sleep apnea (sdOSA) under mandibular advancement device (MAD) therapy.

Methods : Baseline and follow-up polysomnography with MAD were performed. Twenty patients with sdOSA under MAD therapy underwent two consecutive randomized polysomnographies: one with SPT and one with combination of SPT + MAD. Data are presented as median (quartile 1, quartile 3).

Results : The SPT reduced the time spent in supine sleeping position compared to baseline and MAD therapy. Both MAD and SPT were individually effective in reducing the overall apnea/hypopnea index (AHI) significantly when compared to baseline from 20.8 (15.1; 33.6)/h at baseline to 11.0 (6.7; 13.8)/h and to 11.1 (3.5; 17.7)/h with MAD or SPT, respectively. The combination of SPT + MAD further reduced the overall AHI to 5.7 (3.6; 7.4), which was significantly lower than with MAD alone (p < 0.001) and SPT alone (p < 0.008), respectively.

Conclusions : The results of this study indicate that combination of SPT + MAD leads to a higher therapeutic efficacy in patients with sdOSA under MAD therapy when compared to one of the treatment modalities alone.

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Although asthma has long been considered a heterogeneous disease, attempts to define subgroups of asthma have been limited. In recent years both clinical and statistical approaches have been utilized to better merge clinical characteristics, biology and genetics. These combined characteristics have been used to define "phenotypes" of asthma, the observable characteristics of a patient determined by the interaction of genes and environment. Identification of consistent clinical phenotypes has been reported across studies. Now the addition of various 'omics and identification of specific molecular pathways has moved the concept of clinical phenotypes towards the concept of molecular phenotypes.

The importance of these molecular phenotypes is being confirmed through the integration of molecularly targeted biologic therapies. Thus, the term global asthma is poised to become obsolete, being replaced by terms which more specifically identify the pathology associated with the disease.

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In epidemiological studies of asthma, questionnaires to differentiate asthmatics from non-asthmatics have proven to be cost-effective and convenient. The aim of this study was to analyze the association between hyperresponsiveness to methacholine and the validity of five items for the asthma like questionnaire recommended by the Global Initiative for Asthma (GINA).

METHODS: A total of 680 subjects who visited the pulmonology department with suspected symptoms of asthma were enrolled. All participants completed five items questionnaires and underwent methacholine bronchial provocation tests (MBPT). The diagnostic value of the questionnaire was assessed through analysis of the sensitivity, specificity, and positive and negative predictive values.

RESULTS: Multivariate logistic regression analysis showed that questionnaires about wheezing, exercise induced dyspnea and pollution-induced dyspnea were useful for differentiating asthmatics from non-asthmatics (adjusted odds ratio (OR) =2.0, 95% confidence interval (CI) 1.3-3.0; OR =2.3, 95% CI 1.5-3.5; OR =2.0, 95% CI 1.3-3.0) respectively. A total symptom score of higher than 1 was associated with the highest sensitivity (98.4%) and lowest specificity (9.4%). In contrast, a total symptom score of more than 5 was associated with the highest specificity (91.9%) and lowest sensitivity (18.5%)

CONCLUSIONS: Although questionnaires are not a sufficiently accurate method for diagnosing asthma, properly selected questionnaire can be used as effective strategies in situations such as private clinics or large population based epidemiologic studies.

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Fractional exhaled nitric oxide (FeNO) is a surrogate marker of eosinophilic airway inflammation in asthma. The randomized controlled parallel study published by Peirsman et al combined GINA guidelines and FeNO level in guiding drug treatment in children with mild to severe asthma.

Their target was to control the FeNO level below 20 ppb. The FeNO group resulted in increasing the dosage of inhaled corticosteroid and the usage of leukotriene receptor antagonist. However, the study was not truly randomized and drug adherence was not reported. The FeNO-guided algorithm failed to improve the primary outcome, the symptom-free days, but did result in decreasing the number of acute exacerbations and unscheduled contacts.

Unfortunately the authors did not demonstrate a persistent and significant difference in FeNO levels between both groups. As the final FeNO levels were not reported, it remains unclear whether their target was met. Pediatr Pulmonol. © 2014 Wiley Periodicals, Inc.

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