Sleep and long COVID: Preexisting sleep issues and the risk of PASC in a large general population using 3 different model definitions.

Study Objectives: Insomnia, poor sleep quality and extremes of sleep duration are associated with COVID-19 infection. This study assessed whether these factors are related to Post-Acute Sequelae of SARS-CoV-2 infection (PASC). Methods: Cross-sectional survey of a general population of 24,803 U.S. adults to determine the association of insomnia, poor sleep quality and sleep duration with PASC. Results: Prevalence rates of PASC among previously COVID-19 infected participants for three definitions of PASC were COPE (21.9%), NICE (38.9%) and RECOVER PASC Score (15.3%). PASC was associated with insomnia in all 3 models in fully adjusted models with adjusted odds ratios (aORs) and 95% confidence intervals (CI) ranging from 1.30 (95% CI: 1.11-1.52, p≤0.05, PASC Score) to 1.52 (95% CI: 1.34-1.71, p≤0.001, (NICE). Poor sleep quality was related to PASC in all models with aORs ranging from 1.77 (95% CI: 1.60-1.97, p≤0.001, NICE) to 2.00 (95% CI: 1.77-2.26, p≤0.001, COPE). Sleep <6 hours was associated with PASC with aORs between 1.59 (95% CI: 1.40-1.80, p≤0.001, PASC Score) to 1.70 (95% CI: 1.53-1.89, p≤0.001, COPE). Sleep ≥ 9 hours was not associated with PASC in any model. Although vaccination with COVID-19 booster decreased the likelihood of developing PASC, it did not attenuate associations between insomnia, poor sleep quality and short sleep duration with PASC in any of the models. Conclusions: Insomnia, poor sleep quality and short sleep duration are potential risk factors for PASC. Interventions to improve sleep may decrease the development of PASC.

Rapid Online Data Collection and Reporting to Local Health Departments during the Pandemic: The COVID-19 Outbreak Public Evaluation (COPE) Initiative SARS-CoV-2 Case Surveys.

OBJECTIVES: To develop and implement a pilot online data collection tool to help local health departments with their COVID-19 pandemic response efforts and inform health department actions. DESIGN: The COVID-19 Outbreak Public Evaluation (COPE) was an online survey and was distributed by participating sites to individuals who recently tested positive for SARS-CoV-2. Surveys recorded participant demographics and assessed recent infection risk behaviors (eg, mask use, air travel), vaccination status, sleep and exercise habits, social behaviors and beliefs, and physical and mental health. SETTING: Seven health departments participated in the initiative, which took place during May 1 to September 30, 2022. Identical items were administered to demographically representative samples of adults nationally in the United States within a similar timeframe. PARTICIPANTS: A total of 38 555 participants completed surveys. Responses from participants with recent SARS-CoV-2 infections were compared with respondents from the national surveys who did not have evidence or awareness of prior SARS-CoV-2 infections. MAIN OUTCOME MEASURE: To implement of a process that allows health departments to receive data from local cases and compare this information to national controls during the COVID-19 pandemic. RESULTS: Fifty-four biweekly reports were provided to public health departments between May and September 2022. Information and comparisons within the reports were updated in response to evolving public health priorities for the pandemic response. The initiative helped to guide public health response efforts during the COVID-19 pandemic. Moreover, the receptiveness by local health departments and participants provides evidence to support this data collection and reporting model as a component of the public health response to future emergencies. CONCLUSION: This project demonstrates the feasibility of a centralized, rapid, and adaptive data collection system for local health departments and provides evidence to advocate for data collection methods to help guide local health departments to respond in a timely and effective manner to future public health emergencies.

SleepSync: Early Testing of a Personalised Sleep-Wake Management Smartphone Application for Improving Sleep and Cognitive Fitness in Defence Shift Workers.

Shift work, long work hours, and operational tasks contribute to sleep and circadian disruption in defence personnel, with profound impacts on cognition. To address this, a digital technology, the SleepSync app, was designed for use in defence. A pre-post design study was undertaken to examine whether four weeks app use improved sleep and cognitive fitness (high performance neurocognition) in a cohort of shift workers from the Royal Australian Air Force. In total, 13 of approximately 20 shift-working personnel from one base volunteered for the study. Sleep outcomes were assessed using the Insomnia Severity Index (ISI), the Patient-Reported Outcomes Measurement Information System (PROMIS), Sleep Disturbance and Sleep-Related Impairment Scales, the Glasgow Sleep Effort Scale, the Sleep Hygiene Index, and mental health was assessed using the Depression, Anxiety, and Stress Scale-21. Sustained attention was measured using the 3-min Psychomotor Vigilance Task (PVT) and controlled response using the NBack. Results showed significant improvements in insomnia (ISI scores 10.31 at baseline and 7.50 after app use), sleep-related impairments (SRI T-scores 53.03 at baseline to 46.75 post-app use), and healthy sleep practices (SHI scores 21.61 at baseline to 18.83 post-app use; all p < 0.001). Trends for improvement were recorded for depression. NBack incorrect responses reduced significantly (9.36 at baseline; reduced by -3.87 at last week of app use, p < 0.001), but no other objective measures improved. These findings suggest that SleepSync may improve sleep and positively enhance cognitive fitness but warrants further investigation in large samples. Randomised control trials with other cohorts of defence personnel are needed to confirm the utility of this intervention in defence settings.

Histopathological characterization and grading of chronic enterocolitis in Sulawesi crested macaques (Macaca nigra).

Sulawesi crested macaques (Macaca nigra) (SCMs) are critically endangered and frequently suffer from chronic intestinal disease in captivity. Often, despite routine diagnostic investigations and confirmation of intestinal inflammation, an aetiology cannot be identified, leading to a non-specific categorization as chronic enterocolitis rather than an aetiological diagnosis. This study evaluates the histological features of gastrointestinal tissues from 23 SCMs, comparing animals with a clinical history suggestive of chronic enterocolitis (n = 14) with those without gastrointestinal clinical signs (n = 9). Tissues were graded according to the Nancy index (NI), a scoring system used in human medicine to evaluate disease activity in ulcerative colitis, a common form of human inflammatory bowel disease (IBD). Additionally, inflammatory cells in the colonic lamina propria were visually identified by type, counted and subsequently compared between diseased and control animals. Moderate to severe lymphoplasmacytic inflammation and structural changes were most common in the colons of affected SCMs, whereas histopathological changes were absent or mild in all examined small intestine (n = 17) and stomach (n = 11) tissues. The colonic NI had a significant positive correlation with clinical disease severity and 57% (n = 8) of animals with clinical signs had a NI grade of ≥2, consistent with moderate to severe, active IBD. Half of SCMs with recurrent rectal prolapse (n = 6) had a NI grade of 0, suggesting that intestinal inflammation is not always part of this condition's pathogenesis. The numbers of colonic lymphocytes, plasma cells, neutrophils, macrophages and total leucocytes were significantly higher in diseased animals. This study validated the use of the NI in SCMs, enabling a more standardized histopathological evaluation of the colon in this species.

A rapid review of the evidence on models of service delivery for correctional centre-based mothers and children's units: does our approach need to change?

BACKGROUND: Incarcerated mothers are a marginalised group who experience substantial health and social disadvantage and routinely face disruption of family relationships, including loss of custody of their children. To support the parenting role, mothers and children's units (M&Cs) operate in 97 jurisdictions internationally with approximately 19 000 children reported to be residing with their mothers in custody-based settings. AIM: This rapid review aims to describe the existing evidence regarding the models of service delivery for, and key components of, custodial M&Cs. METHOD: A systematic search was conducted of four electronic databases to identify peer-reviewed literature published from 2010 onwards that reported quantitative and qualitative primary studies focused on custody-based M&Cs. Extracted data included unit components, admission and eligibility criteria, evaluations and recommendations. RESULTS: Of 3075 records identified, 35 met inclusion criteria. M&Cs accommodation was purpose-built, incorporated elements of domestic life and offered a family-like environment. Specific workforce training in caring for children and M&Cs evaluations were largely absent. Our systematic synthesis generated a list of key components for M&C design and service delivery. These components include timely and transparent access to information and knowledge for women, evaluation of the impact of the prison environment on M&C, and organisational opportunities and limitations. CONCLUSION: The next generation of M&Cs requires evidence-based key components that are implemented systematically and is evaluated. To achieve this, the use of codesign is a proven method for developing tailored programmes. Such units must offer a net benefit to both mothers and their children.

Association of Chronotype and Shiftwork With COVID-19 Infection.

OBJECTIVE: This study assesses whether chronotype is related to COVID-19 infection and whether there is an interaction with shift work. Methods: This study used a cross-sectional survey of 19,821 U.S. adults. Results: COVID-19 infection occurred in 40% of participants, 32.6% morning and 17.2% evening chronotypes. After adjusting for demographic and socioeconomic factors, shift/remote work, sleep duration, and comorbidities, morning chronotype was associated with a higher (adjusted odds ratio [aOR]: 1.15, 95% CI: 1.10-1.21) and evening chronotype with a lower (aOR: 0.82, 95% CI: 0.78-0.87) prevalence of COVID-19 infection in comparison to an intermediate chronotype. Working exclusively night shifts was not associated with higher prevalence of COVID-19. Morning chronotype and working some evening shifts was associated with the highest prevalence of previous COVID-19 infection (aOR: 1.87, 95% CI: 1.28-2.74). Conclusion: Morning chronotype and working a mixture of shifts increase risk of COVID-19 infection.

Venous blood gases in the assessment of respiratory failure in patients undergoing sleep studies: a randomized study.

STUDY OBJECTIVES: Venous blood gases (VBGs) are not consistently considered suitable surrogates for arterial blood gases (ABGs) in assessing acute respiratory failure due to variable measurement error. The physiological stability of patients with chronic ventilatory failure may lead to improved agreement in this setting. METHODS: Adults requiring ABGs for sleep or ventilation titration studies had VBGs drawn before or after each ABG, in a randomized order. Veno-arterial correlation and agreement were examined for carbon dioxide tension (PCO2), pH, oxygen tension (PO2) and oxygen saturation (SO2). RESULTS: We analyzed 115 VBG-ABG pairs from 61 patients. Arterial and venous measures were correlated (with p<0.05) for PCO2 (r=0.84) and pH (r=0.72), but not for PO2 or SO2. Adjusted mean veno-arterial differences (95% limits of agreement) were +5.0mmHg (-4.4 to +14.4) for PCO2; -0.02 (-0.09 to +0.04) for pH; -34.3mmHg (-78.5 to +10.0) for PO2; and -23.9% (-61.3 to +13.5) for SO2. VBGs obtained from the dorsal hand demonstrated a lower mean PCO2 veno-arterial difference (p<0.01). A venous PCO2 threshold of ≥45.8mmHg was >95% sensitive for arterial hypercapnia, so measurements below this can exclude the diagnosis without an ABG. A venous PCO2 threshold of ≥53.7mmHg was >95% specific for arterial hypercapnia, so such readings can be assumed diagnostic. The area under the receiver operating characteristic curve of 0.91 indicated high discriminatory capacity. CONCLUSIONS: A venous PCO2 <45.8mmHg or ≥53.7mmHg would exclude or diagnose hypercapnia, respectively, in patients referred for sleep studies, but VBGs are poor surrogates for ABGs where precision is important. CLINICAL TRIAL REGISTRATION: Registry: Australian New Zealand Clinical Trials Register; Name: A comparison of arterial and blood gas analyses in sleep studies; Identifier: ACTRN12617000562370; URL https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=372717.

Association of Obstructive Sleep Apnea with Post-Acute Sequelae of SARS-CoV-2 Infection.

BACKGROUND: Obstructive sleep apnea is associated with COVID-19 infection. Less clear is whether obstructive sleep apnea is a risk factor for the development of post-acute sequelae of SARS-CoV-2 infection (PASC). STUDY DESIGN: Cross-sectional survey of a general population of 24,803 US adults to determine the association of obstructive sleep apnea with PASC. RESULTS: COVID-19 infection occurred in 10,324 (41.6%) participants. Prevalence of persistent (>3 months post infection) putative PASC-related physical and mental health symptoms ranged from 6.5% (peripheral edema) to 19.6% (nervous/anxious). In logistic regression models, obstructive sleep apnea was associated with all putative PASC-related symptoms with the highest adjusted odds ratios being fever (2.053) and nervous/anxious (1.939). In 4 logistic regression models of overall PASC derived from elastic net regression, obstructive sleep apnea was associated with PASC (range of adjusted odds ratios: 1.934-2.071); this association was mitigated in those with treated obstructive sleep apnea. In the best fitting overall model requiring ≥3 symptoms, PASC prevalence was 21.9%. CONCLUSION: In a general population sample, obstructive sleep apnea is associated with the development of PASC-related symptoms and a global definition of PASC. Treated obstructive sleep apnea mitigates the latter risk. The presence of 3 or more PASC symptoms may be useful in identifying cases and for future research.

Genetic and epigenetic prognosticators of neuroendocrine tumours of the GI tract, liver, biliary tract and pancreas: A systematic review and meta-analysis.

Multiple recurrent genetic and epigenetic aberrations have been associated with worse prognosis in multiple studies of neuroendocrine tumours (NETs), but these have been mainly small cohorts and univariate analysis. This review and meta-analysis will focus upon the literature available on NETs of the gastrointestinal (GI) tract, liver, biliary tract and pancreas. PubMed and Embase were searched for publications that investigated the prognostic value of (epi)genetic changes of neuroendocrine tumours. A meta-analysis was performed assessing the association of the (epi)genetic alterations with overall survival (OS), disease-free survival (DFS) or locoregional control (LRC). In the pancreas DAXX/ATRX [hazard ratio (HR) = 3.29; 95% confidence interval (CI) = 2.28-4.74] and alternative lengthening telomeres (ALT) activation (HR = 8.20; 95% CI = 1.40-48.07) showed a pooled worse survival. In the small bowel NETs gains on chromosome 14 were associated with worse survival (HR 2.85; 95% CI = 1.40-5.81). NETs from different anatomical locations must be regarded as different biological entities with diverging molecular prognosticators, and epigenetic changes being important to the pathogenesis of these tumours. This review underpins the prognostic drivers of pancreatic NET which lie in mutations of DAXX/ATRX and ALT pathways. However, there is reaffirmation that prognostic molecular biomarkers of small bowel NETs should be sought in copy number variations (CNVs) rather than in single nucleotide variations (SNVs). This review also reveals how little is known about the prognostic significance of epigenetics in NETs.

Subjective awareness of sleepiness while driving in younger and older adults.

Understanding whether drivers can accurately assess sleepiness is essential for educational campaigns advising drivers to stop driving when feeling sleepy. However, few studies have examined this in real-world driving environments, particularly among older drivers who comprise a large proportion of all road users. To examine the accuracy of subjective sleepiness ratings in predicting subsequent driving impairment and physiological drowsiness, 16 younger (21-33 years) and 17 older (50-65 years) adults drove an instrumented vehicle for 2 h on closed loop under two conditions: well-rested and 29 h sleep deprivation. Sleepiness ratings (Karolinska Sleepiness Scale, Likelihood of Falling Asleep scale, Sleepiness Symptoms Questionnaire) were obtained every 15min, alongside lane deviations, near crash events, and ocular indices of drowsiness. All subjective sleepiness measures increased with sleep deprivation for both age groups (p < 0.013). While most subjective sleepiness ratings significantly predicted driving impairment and drowsiness in younger adults (OR: 1.7-15.6, p < 0.02), this was only apparent for KSS, likelihood of falling asleep, and "difficulty staying in the lane for the older adults" (OR: 2.76-2.86, p = 0.02). This may be due to an altered perception of sleepiness in older adults, or due to lowered objective signs of impairment in the older group. Our data suggest that (i) younger and older drivers are aware of sleepiness; (ii) the best subjective scale may differ across age groups; and (iii) future research should expand on the best subjective measures to inform of crash risk in older adults to inform tailored educational road safety campaigns on signs of sleepiness.

Sleep and mental health among unpaid caregivers of children, adults, and both: United States, 2022.

OBJECTIVES: We sought to characterize sleep and mental health, and their relationship, among unpaid caregivers. METHODS: During March through August 2022, four waves of cross-sectional surveys were administered to US adults using demographic quota sampling and weighting to improve representativeness of the US adult population. RESULTS: Among 19,767 respondents, 6260 (31.7%) identified as serving one or more unpaid caregiving roles. Compared to people without caregiving roles, caregivers more commonly reported sleep duration outside the healthy range (7-9 hours), insomnia symptoms, diagnosed sleep disorders, and more commonly screened positive for anxiety, depression, and burnout symptoms. Multivariable analyses adjusted for demographics characteristics revealed unpaid caregivers had several-fold elevated odds of adverse mental health symptoms; associations were attenuated but remained significant after adjusting for impaired and nonoptimal sleep. CONCLUSIONS: Both sleep and mental health challenges are disproportionately experienced by and commonly co-occur among unpaid caregivers, especially those who care for both children and adults. These populations, which serve critical societal roles, may benefit from enhanced support services to address sleep and mental health.

Static-99R Norms and Cross-Cultural Validity for Australian Aboriginal and Non-Aboriginal Men Convicted of Sexual Offences.

This study examined Static-99R normative data and cross-cultural validity in a sample of 811 Aboriginal and 3257 non-Aboriginal Australian men (N = 4068) serving custodial orders for sexual offences in New South Wales (NSW), Australia. Aboriginal men scored significantly higher on the Static-99R than non-Aboriginal men (M = 4.39 vs. 2.61) and were more likely to be represented in higher categories of risk. The Static-99R showed good discrimination performance for the total sample (AUC = .76; 95% CI = [.73-.80]) and acceptable calibration to expected reoffending rates for routine samples, with slight tendencies towards overestimation. Discrimination accuracy was lower for Aboriginal men (AUC = .68; 95% CI = [.60-77]) than non-Aboriginal men (AUC = .78; 95% CI = [.74-83]) although was significantly better than chance for both groups. Additional analyses indicated that cross-cultural differences in discrimination were partly associated with variance in sample composition between groups. This is the first Australian study to find evidence for significant predictive validity of the Static-99R with Aboriginal men, and while further research is needed, the results provide initial support for cross-cultural applications of the measure in local criminal justice settings.

Maintaining High-Touch in High-Tech Digital Health Monitoring and Multi-Omics Prognostication: Ethical, Equity, and Societal Considerations in Precision Health for Palliative Care.

Advances in digital health, systems biology, environmental monitoring, and artificial intelligence (AI) continue to revolutionize health care, ushering a precision health future. More than disease treatment and prevention, precision health aims at maintaining good health throughout the lifespan. However, how can precision health impact care for people with a terminal or life-limiting condition? We examine here the ethical, equity, and societal/relational implications of two precision health modalities, (1) integrated systems biology/multi-omics analysis for disease prognostication and (2) digital health technologies for health status monitoring and communication. We focus on three main ethical and societal considerations: benefits and risks associated with integration of these modalities into the palliative care system; inclusion of underrepresented and marginalized groups in technology development and deployment; and the impact of high-tech modalities on palliative care's highly personalized and "high-touch" practice. We conclude with 10 recommendations for ensuring that precision health technologies, such as multi-omics prognostication and digital health monitoring, for palliative care are developed, tested, and implemented ethically, inclusively, and equitably.

Associations Between Amyloid Burden, Hypoxemia, Sleep Architecture, and Cognition in Obstructive Sleep Apnea.

BACKGROUND: Obstructive sleep apnea (OSA) is associated with an increased risk of amyloid-ß (Aß) burden, the hallmark of Alzheimer's disease, and cognitive decline. OBJECTIVE: To determine the differential impacts of hypoxemia and slow-wave sleep disruption on brain amyloid burden, and to explore the effects of hypoxemia, slow-wave sleep disruption, and amyloid burden on cognition in individuals with and without OSA. METHODS: Thirty-four individuals with confirmed OSA (mean±SD age 57.5±4.1 years; 19 males) and 12 healthy controls (58.5±4.2 years; 6 males) underwent a clinical polysomnogram, a NAV4694 positron emission tomography (PET) scan for Aß burden, assessment of APOEɛ status and cognitive assessments. Linear hierarchical regressions were conducted to determine the contributions of demographic and sleep variables on amyloid burden and cognition. RESULTS: Aß burden was associated with nocturnal hypoxemia, and impaired verbal episodic memory, autobiographical memory and set shifting. Hypoxemia was correlated with impaired autobiographical memory, and only set shifting performance remained significantly associated with Aß burden when controlling for sleep variables. CONCLUSIONS: Nocturnal hypoxemia was related to brain Aß burden in this sample of OSA participants. Aß burden and hypoxemia had differential impacts on cognition. This study reveals aspects of sleep disturbance in OSA that are most strongly associated with brain Aß burden and poor cognition, which are markers of early Alzheimer's disease. These findings add weight to the possibility that hypoxemia may be causally related to the development of dementia; however, whether it may be a therapeutic target for dementia prevention in OSA is yet to be determined.

Pilot feasibility testing of biomathematical model recommendations for personalising sleep timing in shift workers.

Sleep disturbances and circadian disruption play a central role in adverse health, safety, and performance outcomes in shift workers. While biomathematical models of sleep and alertness can be used to personalise interventions for shift workers, their practical implementation is undertested. This study tested the feasibility of implementing two biomathematical models-the Phillips-Robinson Model and the Model for Arousal Dynamics-in 28 shift-working nurses, 14 in each group. The study examined the overlap and adherence between model recommendations and sleep behaviours, and changes in sleep following the implementation of recommendations. For both groups combined, the mean (SD) percentage overlap between when a model recommended an individual to sleep and when sleep was obtained was 73.62% (10.24%). Adherence between model recommendations and sleep onset and offset times was significantly higher with the Model of Arousal Dynamics compared to the Phillips-Robinson Model. For the Phillips-Robinson model, 27% of sleep onset and 35% of sleep offset times were within ± 30 min of model recommendations. For the Model of Arousal Dynamics, 49% of sleep onset, and 35% of sleep offset times were within ± 30 min of model recommendations. Compared to pre-study, significant improvements were observed post-study for sleep disturbance (Phillips-Robinson Model), and insomnia severity and sleep-related impairments (Model of Arousal Dynamics). Participants reported that using a digital, automated format for the delivery of sleep recommendations would enable greater uptake. These findings provide a positive proof-of-concept for using biomathematical models to recommend sleep in operational contexts.

European NCAP Driver State Monitoring Protocols: Prevalence of Distraction in Naturalistic Driving.

OBJECTIVE: examine the prevalence of driver distraction in naturalistic driving when implementing European New Car Assessment Program (Euro NCAP)-defined distraction behaviours. BACKGROUND: The 2023 introduction of Occupant Status monitoring (OSM) into Euro NCAP will accelerate uptake of Driver State Monitoring (DSM). Euro NCAP outlines distraction behaviours that DSM must detect to earn maximum safety points. Distraction behaviour prevalence and driver alerting and intervention frequency have yet to be examined in naturalistic driving. METHOD: Twenty healthcare workers were provided with an instrumented vehicle for approximately two weeks. Data were continuously monitored with automotive grade DSM during daily work commutes, resulting in 168.8 hours of driver head, eye and gaze tracking. RESULTS: Single long distraction events were the most prevalent, with .89 events/hour. Implementing different thresholds for driving-related and driving-unrelated glance regions impacts alerting rates. Lizard glances (primarily gaze movement) occurred more frequently than owl glances (primarily head movement). Visual time-sharing events occurred at a rate of .21 events/hour. CONCLUSION: Euro NCAP-described driver distraction occurs naturalistically. Lizard glances, requiring gaze tracking, occurred in high frequency relative to owl glances, which only require head tracking, indicating that less sophisticated DSM will miss a substantial amount of distraction events. APPLICATION: This work informs OEMs, DSM manufacturers and regulators of the expected alerting rate of Euro NCAP defined distraction behaviours. Alerting rates will vary with protocol implementation, technology capability, and HMI strategies adopted by the OEMs, in turn impacting safety outcomes, user experience and acceptance of DSM technology.

The role of lung volume recruitment therapy in neuromuscular disease: a narrative review.

Respiratory muscle weakness results in substantial discomfort, disability, and ultimately death in many neuromuscular diseases. Respiratory system impairment manifests as shallow breathing, poor cough and associated difficulty clearing mucus, respiratory tract infections, hypoventilation, sleep-disordered breathing, and chronic ventilatory failure. Ventilatory support (i.e., non-invasive ventilation) is an established and key treatment for the latter. As survival outcomes improve for people living with many neuromuscular diseases, there is a shift towards more proactive and preventative chronic disease multidisciplinary care models that aim to manage symptoms, improve morbidity, and reduce mortality. Clinical care guidelines typically recommend therapies to improve cough effectiveness and mobilise mucus, with the aim of averting acute respiratory compromise or respiratory tract infections. Moreover, preventing recurrent infective episodes may prevent secondary parenchymal pathology and further lung function decline. Regular use of techniques that augment lung volume has similarly been recommended (volume recruitment). It has been speculated that enhancing lung inflation in people with respiratory muscle weakness when well may improve respiratory system "flexibility", mitigate restrictive chest wall disease, and slow lung volume decline. Unfortunately, clinical care guidelines are based largely on clinical rationale and consensus opinion rather than level A evidence. This narrative review outlines the physiological changes that occur in people with neuromuscular disease and how these changes impact on breathing, cough, and respiratory tract infections. The biological rationale for lung volume recruitment is provided, and the clinical trials that examine the immediate, short-term, and longer-term outcomes of lung volume recruitment in paediatric and adult neuromuscular diseases are presented and the results synthesised.