Study Objectives: Oronasal masks are frequently used for continuous positive airway pressure (CPAP) treatment in patients with obstructive sleep apnea (OSA). The aim of this study was to (1) determine if CPAP requirements are higher for oronasal masks compared to nasal mask interfaces and (2) assess whether polysomnography and patient characteristics differed among mask preference groups. Methods: Retrospective analysis of all CPAP implementation polysomnograms between July 2013 and June 2014. Prescribed CPAP level, polysomnography results and patient data were compared according to mask type (n = 358). Results: Oronasal masks were used in 46%, nasal masks in 35% and nasal pillow masks in 19%. There was no difference according to mask type for baseline apnea-hypopnea index (AHI), body mass index (BMI), waist or neck circumference. CPAP level was higher for oronasal masks, 12 (10-15.5) cm H 2 O compared to nasal pillow masks, 11 (8-12.5) cm H 2 O and nasal masks, 10 (8-12) cm H 2 O, p < 0.0001 (Median [interquartile range]). Oronasal mask type, AHI, age, and BMI were independent predictors of a higher CPAP pressure (p < 0.0005, adjusted R 2 = 0.26.). For patients with CPAP ≥ 15 cm H 2 O, there was an odds ratio of 4.5 (95% CI 2.5-8.0) for having an oronasal compared to a nasal or nasal pillow mask. Residual median AHI was higher for oronasal masks (11.3 events/h) than for nasal masks (6.4 events/h) and nasal pillows (6.7 events/h), p < 0.001. Conclusions: Compared to nasal mask types, oronasal masks are associated with higher CPAP pressures (particularly pressures ≥ 15 cm H 2 O) and a higher residual AHI. Further evaluation with a randomized control trial is required to definitively establish the effect of mask type on pressure requirements. Keywords: obstructive sleep apnea, CPAP, treatment, mask, nasal pillows, nasal mask, oronasal mask Commentary: A commentary on this article appears in this issue on page 1209. Citation: Deshpande S, Joosten S, Turton A, Edwards BA, Landry S, Mansfield DR, Hamilton GS. Oronasal masks require a higher pressure than nasal and nasal pillow masks for the treatment of obstructive sleep apnea. J Clin Sleep Med 2016;12(9):1263-1268. I NTRO DUCTI O NObstructive sleep apnea (OSA) is characterized by excessive daytime sleepiness due to recurrent episodes of partial (hypopnea) or complete (apnea) obstruction of the upper airway during sleep. OSA is highly prevalent and moderate-severe OSA is reported to affect 17% of men and 9% of women older than 50 years.1 Untreated OSA is associated with significant morbidity and mortality, with increased risk of hypertension, depression, motor vehicle accidents, cardiovascular disease, and premature death.2-5 The mainstay of therapy for OSA is nocturnal continuous positive airway pressure (CPAP), which prevents collapse by pneumatically splinting the upper airway. CPAP has been shown to reduce daytime somnolence, improve quality of life, and improve nocturnal oxygen saturation. 6 CPAP has also been shown to reduce blood pressure, and in severe OSA, c...

Background and Aim Risk stratification is recommended in all patients with acute variceal bleeding (AVB). It remains unclear whether liver disease severity or upper gastrointestinal bleeding (UGIB) scoring algorithms offer superior predictive ability. We aimed to validate the AIMS65 score as a predictor of mortality in AVB, and to compare AIMS65 with established UGIB and liver disease severity risk stratification scores. Methods International Classification of Diseases, Tenth Revision codes identified patients presenting with AVB to three tertiary centers over a 48‐month period. Patients were risk‐stratified using AIMS65, Rockall, pre‐endoscopy Rockall, Child‐Pugh, Model for End‐stage Liver Disease (MELD) and United Kingdom MELD (UKELD) scores. Primary outcomes were inpatient and 6‐week mortality and inpatient rebleeding. Results Two hundred and twenty‐three patients were included. Inpatient and 6‐week mortality were 13.9% and 15.5% respectively. Prediction of inpatient mortality by AIMS65 (area under the receiver‐operating characteristic curve [AUROC: 0.84]) was equivalent to UGIB (Rockall: 0.79, pre‐Rockall: 0.78) and liver risk scores (MELD: 0.81, UKELD: 0.79, Child‐Pugh: 0.78). AIMS65 score ≥3 best defined high‐ and low‐risk groups for inpatient mortality (mortality 37.7% vs 4.9%). AIMS65 (AUROC: 0.62) was equivalent to UGIB risk scores (pre‐Rockall: 0.64, Rockall: 0.70) in predicting inpatient rebleeding and superior to liver risk scores (MELD: 0.56, UKELD: 0.57, Child‐Pugh: 0.60). Conclusions AIMS65 is equivalent to established UGIB and liver disease severity risk stratification scores in predicting mortality, and superior to liver scores in predicting rebleeding.

Endobronchial ultrasound transbronchial needle aspiration (EBUS TBNA) is an established, minimally invasive way to sample intrathoracic abnormalities. The EBUS scope can be passed into the oesophagus to perform endoscopic ultrasound with bronchoscope-guided fine-needle aspiration (EUS-B-FNA). In cases of suspected lung cancer, a combination of the two techniques is now recommended by consensus guidelines. EBUS TBNA is usually performed by pulmonologists; however, the learning curve for EUS-B-FNA, which may be performed during the same procedure, has not been described.A multicentre, observational Australian study, using prospectively collected data from three experienced pulmonologists was conducted. Cumulative sum (cusum) analysis was used to generate visual learning curves.A total of 152 target lesions were sampled in 137 patients, with an overall sensitivity for malignancy of 94.8%. The sensitivity for malignant lesions outside of the 2009 International Association for the Study of Lung Cancer lymph node map (largely intraparenchymal lesions) was 92.9%. All three operators were competent by conventional cusum criteria. There was one case of pneumothorax, and no episodes of mediastinitis or oesophageal perforation were observed.Our data suggest that experienced pulmonologists can safely and accurately perform EUS-B-FNA, with a high diagnostic sensitivity for both lymph node and non-nodal lesions.

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