Dr Katherine Semple | MBBS (Hons) MPhil FRACP
Thoracic and Sleep Physician
Pulmedica, Greenslopes Private Hospital | t: 07 3847 8890 | f: 07 3847 8891
VMO Mater Adult Hospital
Chronic obstructive pulmonary disease (COPD) and obstructive sleep apnoea (OSA) are both common diseases. Almost 20% of COPD patients also have OSA. The combination is associated with a poor prognosis. Sleep difficulties are common in COPD. Up to 70% of patients with COPD without significant daytime hypoxaemia can have significant oxygen desaturation at night, especially during REM sleep. A high daytime pCO2 is a predictor of nocturnal hypoxaemia and increased mortality.
Patients with a combination of OSA and COPD have more severe hypoxaemia, than if either disease is present in isolation. This is associated with pulmonary hypertension, right heart failure, cardiac arrhythmias and a much higher risk of dying.
Oxygen alone is not sufficient treatment for these patients. COPD patients with untreated OSA have a relative risk of death of 1.8, compared with matched COPD patients who do not have OSA. Overlap syndrome patients also have a higher incidence of COPD admissions. Effective treatment of OSA with CPAP improves survival and reduces hospital admissions. In some patients bilevel non-invasive ventilation (NIV) is required.
Summary
COPD and OSA commonly overlap
and this is associated with a much worse survival. Consider screening patients with moderate to severe COPD for OSA, especially if they have hypercapnoea or pulmonary hypertension. CPAP mitigates the excess morbidity and mortality risk.
Obstructive sleep apnea and asthma.
Salles C(1), Terse-Ramos R, Souza-Machado A, Cruz ÁA. Federal University of Bahia, Salvador, Brazil. J Bras Pneumol. 2013 Sep-Oct;39(5):604-12.
Symptoms of sleep-disordered breathing, especially obstructive sleep apnea syndrome (OSAS), are common in asthma patients and have been associated with asthma severity. It is known that asthma symptoms tend to be more severe at night and that asthma-related deaths are most likely to occur during the night or early morning. Nocturnal symptoms occur in 60-74% of asthma patients and are
markers of inadequate control of the disease. Various pathophysiological mechanisms are related to the worsening of asthma symptoms, OSAS being one of the most important factors.
In patients with asthma, OSAS should be investigated whenever there is inadequate control of symptoms of nocturnal asthma despite the treatment recommended by guidelines having been administered. There is evidence in the literature that the use of continuous positive airway pressure contributes to asthma control in asthma patients with obstructive sleep apnea and uncontrolled asthma.
The prevalence of obstructive sleep apnea in patients with difficult-to-treat asthma.
Guven SF, Dursun AB, Ciftci B, Erkekol FO, Kurt OK. Ataturk Chest Diseases and Thoracic Surgery Training and Research Hospital, SleepDisorders Center Ankara, Turkey. Asian Pac J Allergy Immunol. 2014 Jun;32(2):153-9.
OBJECTIVES: Obstructive sleep apnea (OSA) occurs more commonly in asthma patients than in the general population and can complicate asthma management. The aim oft his study was to evaluate the presence of OSA in patients with difficult-to-treat asthma (DTA) and to investigate the sleep quality in these patients.
METHODS: Patients with DTA were recruited from the adult allergy clinic of atertiary care hospital. After completing the Sleep Questionnaire and Epworth Sleepiness Scale, all participants underwent overnight polysomnography. The demographic and asthma severity assessments included the following measures: the age at diagnosis, duration of illness, smoking and atopy status, results of pulmonary function tests, number of asthma control medications used, and number of
hospitalizations and emergency room visits because of asthma and analgesic hypersensitivity according to apnea-hypopnea index (AHI) scores.
RESULTS: We analyzed 47 (M:9/F:38) DTA patients with a mean age of 48.74±9.45years. The mean duration of asthma was 9.17±6.5 years. Twenty-four (51.1%) patients were atopic. The analgesic hypersensitivity rate was 27.7%. Fourteen patients (29.8%) were former smokers and 2 patients were current smokers. Sleep quality was impaired in all patients. Thirty-five patients (74.5%) had OSA, 11 of whom had mild OSA, and 24 patients had moderate-severe OSA. The presence of OSA was not statistically correlated with asthma characteristics.
CONCLUSION: The study showed that there is a remarkably high prevalence of OSA in DTA. Although no statistically significant relationship between the presence of OSA and clinical asthma characteristics was identified, all DTA patients should be assessed for OSA.
Sleep disorders in asthma and chronic obstructive pulmonary disease (COPD)
Böing S(1), Randerath WJ(2). Institut für Pneumologie an der Universität Witten Herdecke, Germany Ther Umsch. 2014 May;71(5):301-8.
Sleep disturbances (SD) are a frequent finding in patients with asthma and chronic obstructive pulmonary disease (COPD) and have a negative impact on quality of life and the clinical course of the disease. The causes of SD are multiple and include for example respiratory symptoms and comorbidities. On the other hand sleep goes along with multiple physiological changes in respiration, so that sleep itself interacts with asthma and COPD. This interaction favours respiratory symptoms and may lead to hypoxemia and hypercapnia.
A further complication of the respiratory situation and the clinical course can be found in asthma and COPD patients with coexisting obstructive sleep apnea syndrome (OSAS). Due to the heterogeneity of SD in asthma and COPD, a detailed patient survey is the most important diagnostical tool. Based on the survey further technical examinations should be considered.
Treatment strategies for the reduction of SD in asthma and COPD include an optimized medication and treatment of comorbidities. If indicated oxygen therapy, positive pressure breathing and pulmonary rehabilitation can contribute.
Obstructive sleep apnoea and atopy among middle aged COPD and bronchial asthma patients.
Kumar R, Nagar D, Mallick A, Kumar M, Tarke CR, Goel N. Vallabhbhai Patel Chest Institute, University of Delhi, Delhi, India. J Assoc Physicians India. 2013 Sep;61(9):615-8.
BACKGROUND: Obstructive sleep apnoea syndrome is associated with significant morbidity. A high prevalence of obstructive sleep apnoea (OSA) symptoms has been reported in patients with asthma and chronic obstructive pulmonary disease (COPD). There are limited studies regarding relationship between atopy and OSA.
OBJECTIVE: To study the risk of obstructive sleep apnoea among middle aged chronic obstructive pulmonary disease and asthma patients by a home based sleep study and its association with atopy.
METHODS: Patients with asthma and COPD were evaluated for OSA symptoms by Epworth sleepiness scale (ESS) and Berlin questionnaire (BQ). ESS score > or = 9 was considered as high risk for OSA. Patients having high risk for OSA by ESS and BQ were further evaluated for OSA by home based sleep study. Skin prick test against common allergens was done to diagnose atopy in these patients.
RESULTS: Among 400 patients (229, 57.25% male and 171, 42.75% female) 328 were asthmatics and 72 were COPD patients. ESS and BQ was positive in 11.25% (45/400) and 18.25% (73/400) patients respectively. ESS was positive in 10.67% (35/328) of asthma and 13.88% (10/72) of COPD patients. BQ was positive in 18.29% (60/328) of asthmatic and 18.05% (13/72) of COPD patients. Skin prick test was positive in74.16% patients. The maximum positivity was found in asthmatics (139/155, 89.68%) compared to COPD patients (16/155, 10.32%). Skin prick test was done for 40patients out of 73 of Asthma and COPD patients who were found positive by ESS and BQ. 72.5% patients were found to be atopic. Out of 19 patients in whom home polysomnography was done, 13 patients consented for skin prick test with common aeroallergens and 9 (69.23%) patients were found to be atopic.
CONCLUSIONS: There is an increased risk of obstructive sleep apnoea among middle aged chronic obstructive pulmonary disease and asthma patients. Atopy could be associated with OSA.
The association needs to be proved in a larger study.
Associations of moderate to severe asthma with obstructive sleep apnea.
Byun MK, Park SC, Chang YS, Kim YS, Kim SK, Kim HJ, Chang J, Ahn CM, Park MS. Div of Pulm, Department of Internal Medicine, Gangnam Severance Hospital, Yonsei University College of Medicine, Korea. Yonsei Med J. 2013 Jul;54(4):942-8.
PURPOSE: This study aimed to evaluate the correlation between associating factors of moderate to severe asthma with obstructive sleep apnea (OSA).
MATERIALS AND METHODS: One hundred and sixty-seven patients who visited the pulmonary and sleep clinic in Severance Hospital presenting with symptoms of sleep-disordered breathing were evaluated. All subjects were screened with Apnea Link. Thirty-two subjects with a high likelihood of having OSA were assessed with full polysomnography (PSG).
RESULTS: The mean age was 58.8±12.0 years and 58.7% of subjects were male. The mean Apnea Link apnea-hypopnea index (AHI) was 12.7±13.0/hr. The mean Apnea Link AHI for the 32 selected high risk patients of OSA was 22.3±13.2/hr, which was lower than the sleep laboratory-based PSG AHI of 39.1±20.5/hr. When OSA was defined at an Apnea Link AHI≥5/hr, the positive correlating factors for OSA were age, male gender, and moderate to severe asthma.
CONCLUSION: Moderate to severe asthma showed strong correlation with OSA when defined at an Apnea Link AHI≥5/hr
The effect of continuous positive airway pressure on stair-climbing performance in severe COPD patients.
Walterspacher S, Walker DJ, Kabitz HJ, Windisch W, Dreher M. University Hospital of Freiburg, Freiburg, Germany. COPD. 2013 Apr;10(2):193-9.
Stair climbing is associated with dynamic pulmonary hyperinflation and the development of severe dyspnea in patients with chronic obstructive pulmonary disease (COPD). This study aimed to assess whether (i) continuous positive airway pressure (CPAP) applied during stair climbing prevents dynamic hyperinflation and thereby reduces exercise-induced dyspnea in oxygen-dependent COPD-patients, and (ii) the CPAP-device and oxygen tank can be carried in a hip belt.
In a
randomised cross-over design, oxygen-dependent COPD patients performed two stair-climbing tests (44 steps): with supplemental oxygen only, then with the addition of CPAP (7 mbar). The oxygen tank and CPAP-device were carried in a hip belt during both trials. Eighteen COPD patients were included in the study. Although all patients could tolerate stair climbing with oxygen alone, 4 patients were unable to perform stair climbing while using CPAP.
Fourteen COPD patients (mean FEV1 36 ± 14% pred.) completed the trial and were analyzed. The mean flow rate of supplemental oxygen was 3 ± 2 l/min during stair climbing. Lung hyperinflation, deoxygenation, hypoventilation, blood lactate production, dyspnea and the time needed to manage stair climbing were not improved by the application of CPAP (all p > 0.05). However, in comparison to climbing with oxygen alone, limb discomfort was reduced when oxygen was supplemented with CPAP (p = 0.008).
In conclusion, very severe COPD patients are able to carry supporting devices such as oxygen tanks or CPAP-devices in a hip belt during stair climbing. However, the application of CPAP in addition to supplemental oxygen during stair climbing prevents neither exercise-induced dynamic hyperinflation, nor dyspnea.
