Sunday, January 31, 2016

Online survey: Impact of social media on promotion of lung health

Dear Respiratory Friends,
We are happy to invite you to participate in our Survey: Impact of social media on promotion of lung health!
Your input will help us to review role of social media in respiratory healthcare and guide the development of it in near future

Please fill out our questionnaire

Saturday, January 30, 2016

Defining the Asthma-COPD Overlap Syndrome in a COPD Cohort (Chest article)

Asthma-COPD overlap syndrome is very contradictory topic in Respiratory medicine!
Background  Asthma-COPD overlap syndrome (ACOS) has been recently described by international guidelines. A stepwise approach to diagnosis using usual features of both diseases is recommended although its clinical application is difficult.

Methods  To identify patients with ACOS, a cohort of well-characterized patients with COPD and up to 1 year of follow-up was analyzed. We evaluated the presence of specific characteristics associated with asthma in this COPD cohort, divided into major criteria (bronchodilator test > 400 mL and 15% and past medical history of asthma) and minor criteria (blood eosinophils > 5%, IgE > 100 IU/mL, or two separate bronchodilator tests > 200 mL and 12%). We defined ACOS by the presence of one major criterion or two minor criteria. Baseline characteristics, health status (COPD Assessment Test [CAT]), BMI, airflow obstruction, dyspnea, and exercise capacity (BODE) index, rate of exacerbations, and mortality up to 1 year of follow-up were compared between patients with and without criteria for ACOS.
Results  Of 831 patients with COPD included,125 (15%) fulfilled the criteria for ACOS, and 98.4% of them sustained these criteria after 1 year. Patients with ACOS were predominantly male (81.6%), with symptomatic mild to moderate disease (67%), who were receiving inhaled corticosteroids (63.2%). There were no significant differences in baseline characteristics, and only survival was worse in patients with non-ACOS COPD after 1 year of follow-up (P < .05).
Conclusions  The proposed ACOS criteria are present in 15% of a cohort of patients with COPD and these patients show better 1-year prognosis than clinically similar patients with COPD with no ACOS criteria.
Full text:

Monday, January 25, 2016

An essential journal on Respiratory Medicine

Current Respiratory Medicine Reviews publishes original research papers, frontier reviews, drug clinical trial studies and guest edited issues dedicated to clinical research on all the latest advances on respiratory diseases and its related areas e.g. pharmacology, pathogenesis, clinical care, therapy. The journal is essential reading for all researchers and clinicians in respiratory medicine.

Saturday, January 23, 2016

2016 Chest Guidelines on Treatment of Unexplained Chronic Cough (free full text)

Unexplained chronic cough (UCC) causes significant impairments in quality of life. Effective assessment and treatment approaches are needed for UCC.

Summary of Recommendations and Suggestions
1. In adult patients with chronic cough, we suggest that unexplained chronic cough be defined as a cough that persists longer than 8 weeks, and remains unexplained after investigation, and supervised therapeutic trial(s) conducted according to published best-practice guidelines (Ungraded Consensus-Based Statement).
2. In adult patients with chronic cough, we suggest that patients with chronic cough undergo a guideline/protocol based assessment process that includes objective testing for bronchial hyperresponsiveness and eosinophilic bronchitis, or a therapeutic corticosteroid trial (Ungraded Consensus-Based Statement).
3. In adult patients with unexplained chronic cough, we suggest a therapeutic trial of multimodality speech pathology therapy (Grade 2C).
4. In adult patientswith unexplained chronic cough and negative tests for bronchial hyperresponsiveness and eosinophilia (sputum eosinophils, exhaled nitric oxide), we suggest that inhaled corticosteroids not be prescribed (Grade 2B).
5. Inadult patients with unexplained chronic cough, we suggest a therapeutic trial of gabapentin as long as the potential side effects and the risk-benefit profile are discussed with patients before use of the medication, and there is a reassessment of the risk-benefit profile at 6 months before continuing the drug (Grade 2C).


Cigarette pollution is much higher than the heavy duty truck one

We are presenting you very interesting study by our Italian friends published in Multidisciplinary Respiratory Medicine: Particulate matters from diesel heavy duty trucks exhaust versus cigarettes emissions: a new educational antismoking instrument.


Indoor smoking in public places and workplaces is forbidden in Italy since 2003, but some health concerns are arising from outdoor secondhand smoke (SHS) exposure for non-smokers. One of the biggest Italian Steel Manufacturer, with several factories in Italy and abroad, the Marcegaglia Group, recently introduced the outdoor smoking ban within the perimeter of all their factories. In order to encourage their smoker employees to quit, the Marcegaglia management decided to set up an educational framework by measuring the PM1, PM2.5 and PM10 emissions from heavy duty trucks and to compare them with the emissions of cigarettes in an indoor controlled environment under the same conditions.
The exhaust pipe of two trucks powered by a diesel engine of about 13.000/14.000 cc3 were connected with a flexible hose to a hole in the window of a container of 36 m3 volume used as field office. The trucks operated idling for 8 min and then, after adequate office ventilation, a smoker smoked a cigarette. Particulate matter emission was thereafter analyzed.

Cigarette pollution was much higher than the heavy duty truck one. Mean of the two tests was: PM1 truck 125.0(47.0), cigarettes 231.7(90.9) p = 0.002; PM2.5 truck 250.8(98.7), cigarettes 591.8(306.1) p = 0.006; PM10 truck 255.8(52.4), cigarettes 624.0(321.6) p = 0.002.


Our findings may be important for policies that aim reducing outdoor SHS exposure. They may also help smokers to quit tobacco dependence by giving them an educational perspective that rebuts the common alibi that traffic pollution is more dangerous than cigarettes pollution.

Friday, January 22, 2016

2016 Guidelines on the appropriate use of diagnostic imaging for patients with chest pain by American College of Radiology and the American College of Cardiology

Led by Frank J. Rybicki, MD, PhD; James E. Udelson, MD, FACC; and W. Frank Peacock, MD, co-chairs of the Emergency Department Patients With Chest Pain Writing Panel, two panels of cardiology and radiology specialists reviewed evidence-based medicine, existing guidelines and practice experience to address appropriate use criteria in 20 fundamental clinical scenarios for emergency imaging in patients who present to the emergency department with chest pain. Each recommendation assesses when imaging is useful in a given scenario, as well as what information is provided by the specified imaging procedure.

According to the authors, “imaging appropriateness explicitly considers two questions: [one] is any imaging justified for 20 clinical scenarios that categorize patients after history, physical examination and ancillary testing? And [two] if justified, what meaningful incremental information will an imaging procedure provide?”

The clinical scenarios are divided into leading clinical diagnoses, acute coronary syndrome, pulmonary embolism and acute aortic syndrome, and rated from one through nine using the well-established modified Rand methodology. A fourth category – triple rule-out computerized tomography – was included for the minority of patients for whom a leading diagnosis is not possible. Each procedure also received indications of rarely appropriate, may be appropriate or appropriate.

Rybicki concludes that “this document captures a wide scope of those patients who come to the emergency department with chest pain, although there will always be patients who present unique situations and no document can be a substitute for clinical judgment.” 
Full text:

Tuesday, January 19, 2016

Appropriate Antibiotic Use for Acute Respiratory Tract Infection in Adults: Advice for High-Value Care From the American College of Physicians and the Centers for Disease Control and Prevention

Background: Acute respiratory tract infection (ARTI) is the most common reason for antibiotic prescription in adults. Antibiotics are often inappropriately prescribed for patients with ARTI. This article presents best practices for antibiotic use in healthy adults (those without chronic lung disease or immunocompromising conditions) presenting with ARTI.
Methods: A narrative literature review of evidence about appropriate antibiotic use for ARTI in adults was conducted. The most recent clinical guidelines from professional societies were complemented by meta-analyses, systematic reviews, and randomized clinical trials. To identify evidence-based articles, the Cochrane Library, PubMed, MEDLINE, and EMBASE were searched through September 2015 using the following Medical Subject Headings terms: “acute bronchitis,” “respiratory tract infection,” “pharyngitis,” “rhinosinusitis,” and “the common cold.”

High-Value Care Advice 1: Clinicians should not perform testing or initiate antibiotic therapy in patients with bronchitis unless pneumonia is suspected.
High-Value Care Advice 2: Clinicians should test patients with symptoms suggestive of group A streptococcal pharyngitis (for example, persistent fevers, anterior cervical adenitis, and tonsillopharyngeal exudates or other appropriate combination of symptoms) by rapid antigen detection test and/or culture for group A Streptococcus. Clinicians should treat patients with antibiotics only if they have confirmed streptococcal pharyngitis.
High-Value Care Advice 3: Clinicians should reserve antibiotic treatment for acute rhinosinusitis for patients with persistent symptoms for more than 10 days, onset of severe symptoms or signs of high fever (>39 °C) and purulent nasal discharge or facial pain lasting for at least 3 consecutive days, or onset of worsening symptoms following a typical viral illness that lasted 5 days that was initially improving (double sickening).
High-Value Care Advice 4: Clinicians should not prescribe antibiotics for patients with the common cold.
full text:

Sunday, January 17, 2016

the 24th Congress of the Romanian Society of Pneumology, Poiana Brasov, October 5th-8th 2016

Dear Colleagues,
Dear Collaborators,
I have the pleasure of announcing the 24th Congress of the Romanian Society of Pneumology which will take place in Poiana Brasov between October 5th-8th 2016. This is the natural continuance of the high scientific events that you have all been accustomed already in the previous years; therefore it stays in the responsibility of the organizers to ensure the continuity of values and the promotion of medical novelty.

Pneumology has met a wide development in the last 25 years in Romania. The Romanian pneumologists form an exceptional medical community both from the professional Association’s point of view: the Romanian Society of Pneumology being one of the most active and prolific ones of its kind in the country, and from the point of view of the medical activity: diagnostic and modern treatment according to the international standards becoming already a constant concern of each Romanian pneumologist.
What novelties brings this event of Romanian pneumologists? We propose two directions. The congress will represent a bridge between generations. First, we will encourage involving the young pneumologists, because creating the new generations of specialists in respiratory diseases is essential for the progress of the Romanian field of pneumology. Next to the young ones we want for the senior pneumologists to be present, being invitated throught the financial involvement of the Romanian Society of Pneumology as a humble acknowledgement – of the track records of the forthcoming, development and promotion of the Romanian pneumology as it is presented in today’s medical world.
The second direction goes to the theme of the Congres “ Exacerbation – quo vadis?”, this question refferring to the exacerbation of a series of pulmonary diseases starting with Chronic Obstructive Pulmonary Disease or asthma to infectious diseases with pulmonary interference or idiopatic interstitial fibrosis.
This direction is addressed to specialists in multiple areas of expertise – for as the modern and actual approach of exacerbations in pulmonary pathology is required to be an interdisciplinary one! The treatment of the respiratory diseases becomes more and more personalized and involves a rising number or medical specialties. So far, a specialist was treating A DISEASE. We must learn to treat together, doctors of different specialties, ONE PATIENT in a particular situation with a certain pathological identity. Quo vadis? – the path is being built now. I invite you to define it and to make it together.
I am looking forward to seeing you in Poiana Brasov!
ruxandra Ulmeanu 
Ruxandra Ulmeanu
President of the Congress
Elected President of the Romanian Society of Pneumology (2016-2018)

Saturday, January 16, 2016

“Take 3” Actions to Fight The Flu

Flu is a serious contagious disease that can lead to hospitalization and even death. 
CDC urges you to take the following actions to protect yourself and others from influenza (the flu): 

Take time to get a flu vaccine.

  • CDC recommends a yearly flu vaccine as the first and most important step in protecting against flu viruses.
  • While there are many different flu viruses, a flu vaccine protects against the viruses that research suggests will be most common. 
  • Flu vaccination can reduce flu illnesses, doctors’ visits, and missed work and school due to flu, as well as prevent flu-related hospitalizations and deaths.
  • Everyone 6 months of age and older should get a flu vaccine as soon as the current season's vaccines are available.
  • Vaccination of high risk persons is especially important to decrease their risk of severe flu illness.
  • People at high risk of serious flu complications include young children, pregnant women, people with chronic health conditions like asthma, diabetes or heart and lung disease and people 65 years and older.
  • Vaccination also is important for health care workers, and other people who live with or care for high risk people to keep from spreading flu to them.
  • Children younger than 6 months are at high risk of serious flu illness, but are too young to be vaccinated. People who care for infants should be vaccinated instead.

Take everyday preventive actions to stop the spread of germs.

  • Try to avoid close contact with sick people.
  • While sick, limit contact with others as much as possible to keep from infecting them.
  • If you are sick with flu-like illness, CDC recommends that you stay home for at least 24 hours after your fever is gone except to get medical care or for other necessities. (Your fever should be gone for 24 hours without the use of a fever-reducing medicine.)
  • Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash after you use it.
  • Wash your hands often with soap and water. If soap and water are not available, use an alcohol-based hand rub.
  • Avoid touching your eyes, nose and mouth. Germs spread this way.
  • Clean and disinfect surfaces and objects that may be contaminated with germs like the flu.

Take flu antiviral drugs if your doctor prescribes them.

  • If you get the flu, antiviral drugs can be used to treat your illness.
  • Antiviral drugs are different from antibiotics. They are prescription medicines (pills, liquid or an inhaled powder) and are not available over-the-counter.
  • Antiviral drugs can make illness milder and shorten the time you are sick. They may also prevent serious flu complications. 
  • treatment with an antiviral drug can mean the difference between having a milder illness versus a very serious illness that could result in a hospital stay.
  • Studies show that flu antiviral drugs work best for treatment when they are started within 2 days of getting sick, but starting them later can still be helpful, especially if the sick person has a high-risk health condition or is very sick from the flu. Follow your doctor’s instructions for taking this drug.
  • Flu-like symptoms include fever, cough, sore throat, runny or stuffy nose, body aches, headache, chills and fatigue. Some people also may have vomiting and diarrhea. People may be infected with the flu, and have respiratory symptoms without a fever.

Friday, January 15, 2016

Meeting with journalists: "About smoking: from theory to the public" By Professor Florin Mihălțan, chairman of the Romanian Society of Pulmonology

Smoke-free law enforcement is one of the major priorities on the Romanian Society of Pulmonology agenda.
Our mission is to have a comprehensive smoke-free law, which can not only be accepted but also be applied and monitored. Furthermore, we need educational packages, higher taxes on tobacco and high-impact pictograms, in order to drastically reduce tobacco consumption among Romanians.
The Romanian Society of Pulmonology, an organisation that has been involved for several years in the implementation of a smoke-free law, brought together important opinion leaders in the field of pulmonology and cardiology, public health professionals, authorities, social life representatives and journalists, in order to introduce a mutual goal: an accurate and more effective communication of topics regarding smoking in Romania.
The Romanian Society of Pulmonology’s steps for implementing legislation that prohibits smoking in public places, as well as for reducing the number of smokers, represent actions intended to align Romania to global health policy. Since last year, the action plan was founded on a solid partnership between the Romanian Society of Pulmonology and the Romanian Society of Cardiology.
The implementation of smoke-free law and the attempt to change social behaviour are slow and difficult, therefore the initiative requires partnerships. The cardiologists who attended the meeting highlighted the importance of partnerships between medical societies involved in combating smoking, in order to have a deeper impact at the social level.
These actions are all the more pressing since the risk of myocardial infarction in young smokers is high in Romania. Another important topic the experts approached was education as an important element in terms of raising awareness regarding the risks of smoking.
The representatives of the authorities admitted that, unfortunately, Romania is the only country in the European Union which has not adopted legislation to ban smoking in enclosed public places, emphasising that Romania should reach the European standards. However, there is an optimistic attitude regarding the adoption of smoke-free law and the hope that the lawmakers will reach a consensus in applying the law, which will also bring a beneficial change at the community level.
The civil society representatives argued that the implementation of the smoke-free law protects the rights of non-smokers and helps them to enjoy the fresh air in public spaces. They also pointed out the long term repercussions that tobacco consumption has on the economy. If we do a cost-benefit analysis, it would show that, if there is not a responsible intervention the costs associated with hospitalisation, workplace absenteeism, loss of productivity etc., will grow.
In terms of trying to change the behaviour of smokers, specialists rely heavily on reverse psychology, communication more about the positive effects of quitting smoking and less on the negative effects of nicotine addiction. The impact of the meeting was positive in terms of media representation. The event had a good coverage on Romanian TV channels, radio and online media.

Tuesday, January 12, 2016

Pneumologia - Journal of the Romanian Society of Pulmonology: Predictors of daytime sleepiness in patients with obstructive sleep apnea

Background. The main symptomatic criterion to diagnose obstructive sleep apnea (OSA) is the level of daytime sleepiness. The Epworth Sleepiness Scale is a simple, self-administered questionnaire which provides a measurement of the subject’s general level of daytime sleepiness.
The aim of this study was to investigate the factors that can predict daytime sleepiness in patients with sleep apnea.
Conclusion. The desaturation index showed the
strongest correlation with the Epworth scale. According to the results of the backward stepwise multiple regression and logistic regression, the predictors for the level of daytime sleepiness are oAHI and index of desaturation. According to the analysis of the ROC curve, desaturation index is a predictor of a high specificity.
on researchgate:

Friday, January 8, 2016

How to Recycle One of the Most Common Kinds of Litter in the World

Cigarette butts are one of the most common kinds of litter, found everywhere from land to waterways. The tobacco and paper in them will break down, so those can be composted. But the filters contain a plastic, and that can take years to decompose. Yet if the butts are carefully processed, the cellulose acetate can be used to make things such as park benches and pallets. Recycling companies like TerraCycle are also refining their processing methods to create higher-end plastic products.

Thursday, January 7, 2016

2016 CHEST issues new antithrombotic guideline update for treatment of VTE disease

Glenview, Ill.— Each year, there are approximately 10 million cases of venous thromboembolism (VTE) worldwide. VTE, the formation of blood clots in the vein, is a dangerous and potentially deadly medical condition and is a leading cause of death and disability worldwide. In this latest evidence-based guideline, Antithrombotic Therapy for VTE Disease: CHEST Guideline, from the American College of Chest Physicians, experts provide 53 updated recommendations for appropriate treatment of patients with VTE.  
“This guideline article, another from CHEST living guidelines, provides the most up-to-date treatment options for patients with VTE. The guideline presents stronger recommendations and weaker suggestions for treatment based on the best available evidence, and identifies gaps in our knowledge and areas for future research,” said lead author Clive Kearon, MD, McMaster University.
Key changes to recommendations in the 9th edition to the 10th edition include: 
  • Non-vitamin K antagonist oral anticoagulants (NOACs) are suggested over warfarin for initial and long-term treatment of VTE in patients without cancer.  Since publication of the 9th edition, new studies show that NOACs are as effective as VKA therapy with reduced risk of bleeding and increased convenience for patients and health-care providers.
  • Routine use of compression stockings is out to prevent postthrombotic syndrome in acute DVT. Based on recent evidence, the 10th edition suggests not to routinely use compression stockings to prevent postthrombotic syndrome in patients with acute DVT. Postthrombotic syndrome is a chronic condition of the leg with swelling, pain, skin discoloration, and even ulcers.  In the 9th edition, compression stockings were routinely suggested as a preventive measure in these patients.
  • New isolated subsegmental pulmonary embolism treatment recommendations. The 10th edition suggests which patients diagnosed with isolated subsegmental pulmonary embolism (SSPE) should, and should not, receive anticoagulant therapy.

Monday, January 4, 2016

New rules on driver licensing for patients with obstructive sleep apnea: European Union Directive 2014/85/EU

The widespread recognition that obstructive sleep apnea (OSA) represents an important risk factor for motor vehicle accidents, which is reversed by successful therapy with continuous positive airway pressure (CPAP), has led to a revision of Annex III of the European Union (EU) Directive on Driving Licences. This directive was the result of recommendations from a Working Group established by the Transport and Mobility Directorate of the European Commission in 2012 (McNicholas, 2013).

The new Directive, which is subject to mandatory implementation by all Member States from 31 December 2015, states:
‘Applicants or drivers in whom a moderate or severe obstructive sleep apnea syndrome is suspected shall be referred to further authorised medical advice before a driving licence is issued or renewed. They may be advised not to drive until confirmation of the diagnosis. Driving licences may be issued to applicants or drivers with moderate or severe obstructive sleep apnea syndrome  who show adequate control of their condition and compliance with appropriate treatment and improvement of sleepiness, if any, confirmed by authorised medical opinion. Applicants or drivers with moderate or severe obstructive sleep apnea syndrome under treatment shall be subject to a periodic medical review, at intervals not exceeding 3 years for drivers of group 1 (i.e. non-commercial drivers) and 1 year for drivers of group 2 (i.e. commercial drivers), with a view to establish the level of compliance with the treatment, the need for continuing the treatment and continued good vigilance.’

Sunday, January 3, 2016

Global Strategy for Diagnosis, Management, and Prevention of COPD - 2016

In 2011, the Global Initiative for Chronic Obstructive Lung Disease (GOLD) released a consensus report, Global Strategy for the Diagnosis, Management, and Prevention of COPD. It recommended a major revision in the management strategy for COPD that was presented in the original 2001 document. Updated reports released in January 2013, January 2014, January 2015, and December 2015 are based on scientific literature published since the completion of the 2011 document but maintain the same treatment paradigm. Assessment of COPD is based on the patient’s level of symptoms, future risk of exacerbations, the severity of the spirometric abnormality, and the identification of comorbidities. The January 2015 update added an Appendix on Asthma COPD Overlap Syndrome, material prepared jointly by the GOLD and GINA Science Committees.
The GOLD report is presented as a “strategy document” for health care professionals to use as a tool to implement effective management programs based on available health care systems. The quadrant management strategy tool is designed to be used in any clinical setting; it draws together a measure of the impact of the patient’s symptoms and an assessment of the patient’s risk of having a serious adverse health event in the future. Many studies have assessed the utility/relevance of this new tool. Evidence will continue to be evaluated by the GOLD committees and management strategy recommendations modified as required.
GOLD has been fortunate to have a network of international distinguished health professionals from multiple disciplines. Many of these experts have initiated investigations of the causes and prevalence of COPD in their countries, and have developed innovative approaches for the dissemination and implementation of the GOLD management strategy. The GOLD initiative will continue to work with National Leaders and other interested health care professionals to bring COPD to the attention of governments, public health officials, health care workers, and the general public to raise awareness of the burden of COPD and to develop programs for early detection, prevention and approaches to management.
Marc Decramer, MD
Chair, GOLD Board of Directors
Professor of Medicine
CEO University Hospital
University of Leuven, Leuven, Belgium
Claus Vogelmeier, MD
Chair, GOLD Science Committee
Director, Internal Medicine Clinic
University of Giessen and Marburg,
School of Medicine
Standort Marburg Baldingerstrasse
D-35043 Marburg, Germany

Link for free download:

Saturday, January 2, 2016

The bacterial pneumonias: a new treatment paradigm

Pneumonia is a common disease that carries a high mortality. Traditionally, pneumonia has been classified and treated according to the setting where the pneumonia develops, namely community-acquired pneumonia, health-care–associated pneumonia, and hospital-acquired pneumonia. This classification was based on the risk of a patient being infected with a hospital-acquired drug-resistant pathogen.

A new treatment paradigm has been proposed based on the risk of the patient being infected with a community-acquired drug-resistant pathogen. The risk factors for infection with a community-acquired drug-resistant pathogen include (1) hospitalization for > 2 days during the previous 90 days, (2) antibiotic use during the previous 90 days, (3) nonambulatory status, (4) tube feeds, (5) immunocompromised status, (6) use of acid-suppressive therapy, (7) chronic hemodialysis during the preceding 30 days, (8) positive methicillin-resistant Staphylococcus aureus history within the previous 90 days, and (9) present hospitalization > 2 days. This article reviews this new treatment paradigm and other issues relevant to the diagnosis and management of pneumonia based on information from MEDLINE, EMBASE, and the Cochrane Register of Controlled Trials.

Friday, January 1, 2016

2016 Guidelines: obstructive sleep disordered breathing in 2- to 18-year-old children: diagnosis and management

Today in ERJ was published European Respiratory Society on the diagnosis and management of obstructive sleep disordered breathing in childhood!
This document summarises the conclusions of a European Respiratory Society Task Force on the diagnosis and management of obstructive sleep disordered breathing (SDB) in childhood and refers to children aged 2–18 years. Prospective cohort studies describing the natural history of SDB or randomised, double-blind, placebo-controlled trials regarding its management are scarce. Selected evidence (362 articles) can be consolidated into seven management steps. SDB is suspected when symptoms or abnormalities related to upper airway obstruction are present (step 1). Central nervous or cardiovascular system morbidity, growth failure or enuresis and predictors of SDB persistence in the long-term are recognised (steps 2 and 3), and SDB severity is determined objectively preferably using polysomnography (step 4). Children with an apnoea–hypopnoea index (AHI) >5 episodes·h−1, those with an AHI of 1–5 episodes·h−1 and the presence of morbidity or factors predicting SDB persistence, and children with complex conditions (e.g. Down syndrome and Prader–Willi syndrome) all appear to benefit from treatment (step 5). Treatment interventions are usually implemented in a stepwise fashion addressing all abnormalities that predispose to SDB (step 6) with re-evaluation after each intervention to detect residual disease and to determine the need for additional treatment (step 7).