***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVES The aim of this study was to compare the relative efficacy of continuous positive airway pressure ( CPAP ) and positional treatment in the management of positional obstructive sleep apnea ( OSA ) , using objective outcome measures . DESIGN A prospect i ve , r and omized , single blind crossover comparison of CPAP and positional treatment for 2 weeks each . SETTING A university teaching hospital . PATIENTS Thirteen patients with positional OSA , aged ( mean+/-SD ) 51+/-9 years , with an apnea-hypopnea index ( AHI ) of 17+/-8 . MEASUREMENTS ( 1 ) Daily Epworth Sleepiness Scale scores ; ( 2 ) overnight polysomnography , an objective assessment of sleep quality and AHI ; ( 3 ) maintenance of wakefulness testing ; ( 4 ) psychometric test battery ; ( 5 ) mood scales ; ( 6 ) quality -of-life question naires ; and ( 7 ) individual patient 's treatment preference . RESULTS Positional treatment was highly effective in reducing time spent supine ( median , 0 ; range , 0 to 32 min ) . The AHI was lower ( mean difference , 6.1 ; 95 % confidence interval [ CI ] , 2 to 10.2 ; p = 0.007 ) , and the minimum oxygen saturation was higher ( 4 % ; 95 % CI , 1 % to 8 % ; p = 0.02 ) on CPAP as compared with positional treatment . There was no significant difference , however , in sleep architecture , Epworth Sleepiness Scale scores , maintenance of wakefulness testing sleep latency , psychometric test performance , mood scales , or quality -of-life measures . CONCLUSION Positional treatment and CPAP have similar efficacy in the treatment of patients with positional OSA BACKGROUND Although early intubation to prevent the mortality that accompanies hypoxia is considered the st and ard of care for severe traumatic brain injury ( TBI ) , the efficacy of this approach remains unproven . METHODS Patients with moderate to severe TBI ( Head/Neck Abbreviated Injury Scale [ AIS ] score 3 + ) were identified from our county trauma registry .  Logistic regression was used to explore the impact of prehospital intubation on outcome , controlling for age , gender , mechanism , Glasgow Coma Scale score , Head/Neck AIS score , Injury Severity Score , and hypotension . Neural network analysis was performed to identify patients predicted to benefit from prehospital intubation . RESULTS A total of 13,625 patients from five trauma centers were included ;  overall mortality was 22.9 % , and 19.3 % underwent prehospital intubation . Logistic regression revealed an increase in mortality with prehospital intubation ( odds ratio , 0.36 ; 95 % confidence interval , 0.32 - 0.42 ; p < 0.001 ) . This was true for all patients , for those with severe TBI ( Head/Neck AIS score 4 + and /or Glasgow Coma Scale score of 3 - 8 ) , and with exclusion of patients transported by aeromedical crews . Patients intubated in the field versus the emergency department had worse outcomes . Neural network analysis identified a subgroup of patients with more significant injuries as potentially benefiting from prehospital intubation . CONCLUSION Prehospital intubation is associated with a decrease in survival among patients with moderate-to-severe TBI . More critically injured patients may benefit from prehospital intubation but may be difficult to identify prospect ively STUDY OBJECTIVES We hypothesized that positional therapy would be equivalent to continuous positive airway pressure ( CPAP ) at normalizing the apnea-hypopnea index ( AHI ) in patients with positional obstructive sleep apnea ( OSA ) . METHODS Thirty-eight patients ( 25 men , 49 + /- 12 years of age , body mass index 31 + /- 5 kg/m2 ) with positional OSA ( nonsupine AHI < 5 events/h ) identified on a baseline polysomnogram were studied . Patients were r and omly assigned to a night with a positional device ( PD ) and a night on CPAP ( 10 + /- 3 cm H2O ) . RESULTS Positional therapy was equivalent to CPAP at normalizing the AHI to less than 5 events per hour ( 92 % and 97 % , respectively [ p = 0.16 ] ) . The AHI decreased from a median of 11 events per hour ( interquartile range 9 - 15 , range 6 - 26 ) to 2 ( 1 - 4 , 0 - 8 ) and 0 events per hour ( 0 - 2 , 0 - 7 ) with the PD and CPAP , respectively ; the difference between treatments was significant ( p < 0.001 ) . The percentage of total sleep time in the supine position decreased from 40 % ( 23%-67 % , 7%-82 % ) to 0 % ( 0%-0 % , 0%-27 % ) with the PD ( p < 0.001 ) but was unchanged with CPAP ( 51 % [ 36%-69 % , 0%-100 % ] ) . The lowest SaO2 increased with the PD and CPAP therapy , from 85 % ( 83%-89 % , 76%-93 % ) to 89 % ( 86%-9%1 , 78%-95 % ) and 89 % ( 87%-91 % , 81%-95 % ) , respectively ( p < 0.001 ) . The total sleep time was unchanged with the PD , but decreased with CPAP , from 338 ( 303 - 374 , 159 - 449 ) minutes to 334 ( 287 - 366 , 194 - 397 ) and 319 ( 266 - 343 , 170 - 386 ) minutes , respectively ( p = 0.02 ) . Sleep efficiency , spontaneous arousal index , and sleep architecture were unchanged with both therapies . CONCLUSION Positional therapy is equivalent to CPAP at normalizing the AHI in patients with positional OSA , with similar effects on sleep quality and nocturnal oxygenation BACKGROUND The upper airway resistance syndrome ( UARS ) is one of the mild variants of obstructive sleep disordered breathing . Nasal obstruction is proposed as one of the mechanisms that lowers intrapharyngeal pressure and hence increases airway collapsibility . OBJECTIVE We evaluated the effect of external nasal dilation and sleep position on sleep in UARS . METHOD A double blind , r and omized , controlled study with a crossover design ( using therapeutic and placebo dilators ) was conducted in 18 consecutive patients with UARS . Each patient had two overnight sleep studies one to two weeks apart . Cardiorespiratory parameters ( AHI , percentage of time that SaO2 was more than 2 % below awake [ desaturation time ] and mean overnight heart rate ) , sleep architecture ( sleep stages , sleep efficiency , and arousal index ) , and body position were determined . RESULTS Application of the external nasal dilator result ed in a significant increase in the nasal cross-sectional area ( p < 0.001 ) . Treatment reduced stage 1 sleep ( as a percent of total sleep time ) from 8.6 + /- 0.8 % to 7.1 + /- 0.7 ( SEM ) , p = 0.034 ) . Desaturation time was significantly lower with treatment ( 12.2 + /- 2.2 % on placebo versus 9.1 + /- 1.3 on treatment , p = 0.04 ) . There were no additional significant effects on the cardiorespiratory parameters , sleep architecture , or MSLT when the entire night was examined . Controlling for interactions of sleep stage and position and treatment we found that treatment reduced desaturation time ( p = 0.03 ) but not AHI or arousal index . AHI was significantly lower in the lateral position compared to the supine ( p = 0.0001 ) and in NREM sleep compared to REM ( p = 0.001 ) . Desaturation time was significantly lower on the lateral compared to the supine position ( p = 0.002 ) and in NREM sleep compared to REM ( p = 0.006 ) . Arousal index was highly dependent on sleep stage ( p = 0.0001 ) : the index was higher in stage 2 compared to slow wave sleep and REM . Sleep position and treatment had no significant effect on arousals . CONCLUSIONS External nasal dilation reduced stage 1 sleep , an indirect marker of disrupted sleep , and desaturation time . There were no additional effects on sleep architecture or sleep disordered breathing . Both sleep position and sleep stage had a significant effect on sleep disordered breathing in UARS Abstract Conclusions : This study has shown that the body mass index ( BMI ) , neck circumference , and modified Mallanpati grade ( MMP ) are predictive of severity of obstructive sleep apnea/hypopnea syndrome ( OSAHS ) . The neck circumference and MMP were revealed to be important morphological features in the responders whose apnea/hyoponea index ( AHI ) was substantially decreased by positioning during sleep . Objective : The aim of this study was to assess the predictive power of routine physical examination of the upper airway by an otorhinolaryngologist to identify OSAHS in Chinese patients , and to clarify the interaction of lateral and supine sleeping positions with upper airway morphology in patients with OSAHS . Methods : In all , 103 consecutive patients with OSAHS ( 48 men and 65 women ) underwent polysomnography and upper airway morphological examination .  Upper airway morphology and anthropometric variables were evaluated to determine different severity of OSAHS in the responders and nonresponders . Results : The neck circumference , BMI , and MMP showed statistical correlations with AHI and decreased AHI for changed sleeping position . Multiple logistic regression analysis showed that the neck circumference and MMP were significant predictors for the responders ( p = 0.023 , odds ratio = 1.180 and p = 0.006 , odds ratio = 1.922 , respectively ) This article introduces the approach of GRADE to rating  quality of evidence .  GRADE specifies four categories-high , moderate , low , and very low-that are applied to a body of evidence , not to individual studies . In the context of a systematic review , quality reflects our confidence that the estimates of the effect are correct . In the context of recommendations , quality reflects our confidence that the effect estimates are adequate to support a particular recommendation . R and omized trials begin as high- quality evidence , observational studies as low quality . " Quality " as used in GRADE means more than risk of bias and so may also be compromised by imprecision , inconsistency , indirectness of study results , and publication bias . In addition , several factors can increase our confidence in an estimate of effect . GRADE provides a systematic approach for considering and reporting each of these factors . GRADE separates the process of assessing quality of evidence from the process of making recommendations . Judgments about the strength of a recommendation depend on more than just the quality of evidence BACKGROUND Obstructive sleep apnea ( OSA ) is common in stroke patients and is associated with poor functional outcome . The effects of positional therapy in ischemic stroke patients with OSA have not been investigated . We tested the hypothesis that ischemic stroke patients have less severe OSA during positional therapy that promotes nonsupine positioning . METHODS We conducted a r and omized , controlled , cross-over study . Sleep apnea screening studies were performed on two consecutive nights , using a portable respiratory monitoring system , on 18 subjects within the first 14days of ischemic stroke .  An apnea-hypopnea index ( AHI ) ⩾5 established the diagnosis of OSA . Subjects were r and omized to  positional therapy that included the use of a therapeutic pillow on either the first or second night . On the control night , subjects used the hospital pillow and were positioned ad lib . Treatment effect on AHI was estimated using a repeated measures model . RESULTS All ischemic stroke subjects studied had OSA . The predominantly male group had a median age of 58years , BMI of 29kg/m(2 ) , NIH Stroke Scale score of 3 , and a median AHI on the nontherapeutic night of 39 ( interquartile range : 21 - 54 ) . Positional therapy reduced the amount of supine positioning by 36 % ( 95 % CI : 18 - 55 % ( P<0.001 ) ) . The AHI was reduced by 19.5 % ( 95 % CI : 4.9 - 31.9 % ( P=0.011 ) ) , when using positional therapy compared to sleeping ad lib . CONCLUSIONS Positional therapy to avoid supine positioning modestly reduces sleep apnea severity after ischemic stroke , and may therefore improve outcomes Obstruction of the upper airway is a major challenge for anesthesiologists administering general anesthesia in spontaneously breathing patients , especially in pediatric anesthesia with adenotonsillar hypertrophy . Lateral positioning is a simple treatment for obstructive sleep apnea and also decreases collapsibility of the pharynx in anesthetized adults with obstructive sleep apnea . In this study , we examined the effects of body position shifting and common airway maneuvers , such as chin lift and jaw thrust , on airway patency ( stridor score ) in anesthetized children scheduled for adenotonsillectomy . Thirty children aged 1–10 yr were anesthetized with sevoflurane .  During spontaneous breathing of 5 % sevoflurane , stridor score was recorded . After baseline recording , chin lift and jaw thrust were performed on patients in both the supine and the lateral decubitus positions . Chin lift and 
    Output:
    
In studies reporting only indirect outcome measures , we found moderate evidence of reduced airway patency in the supine vs. the lateral position , which was measured by the apnea/hypopnea index ( AHI ) .
Conclusions Although concerns other than airway patency may influence how a trauma patient is positioned , our systematic review provides evidence supporting the long held recommendation that unconscious trauma patients should be placed in a lateral position