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Chronic Obstructive Pulmonary Disease & Obstructive Sleep Apnea-Hypopnea Syndrome

Chronic Obstructive Pulmonary Disease & Obstructive Sleep Apnea-Hypopnea Syndrome. “Overlap Syndrome”. COPD. SAHS. Greg Koyama PharmD Candidate, 2014 10/7/13. General Definitions. Chronic Obstructive Pulmonary Disease (COPD) Obstructive Ventilatory Defect FEV1/FEVC ratio <70%

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Chronic Obstructive Pulmonary Disease & Obstructive Sleep Apnea-Hypopnea Syndrome

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  1. Chronic Obstructive Pulmonary Disease &Obstructive Sleep Apnea-Hypopnea Syndrome “Overlap Syndrome” COPD SAHS Greg Koyama PharmD Candidate, 2014 10/7/13

  2. General Definitions • Chronic Obstructive Pulmonary Disease (COPD) • Obstructive Ventilatory Defect • FEV1/FEVC ratio <70% • Obstructive Sleep Apnea-Hypopnea Syndrome (SAHS) • *Presently no standardized definition • Respiratory Disturbance Index (RDI) >10 or >15 • RDI= Composite of average # of apneas + hypoapneas per hour of sleep • Presence of Symptoms: • Daytime Sleepiness • Poor Quality of Sleep • “Overlap Syndrome” • Combination of COPD & SAHS (Flenley, 1985) • *Can apply to SAHS + “any chronic respiratory disorder”

  3. Epidemiology COPD SAHS 5%* 10-20%* Overlap Syndrome 0.5%* ↑ Risk of COPD in SAHS patients? ↑ Risk of SAHS in COPD patients? *Adults over 40 years of age

  4. SAHS-associated COPD ↑ Risk of COPD in SAHS patients? • Chaouat et al. • Inclusion Criteria: SAHS without COPD • n= 265 • Endpoint: Development of COPD over time • 30/265 (11%) had developed COPD • Compare to prevalence of COPD in the general population (10%) No Significant Difference

  5. COPD-associated SAHS ↑ Risk of SAHS in COPD patients? Sleep Heart Health Study—SHHS (2003) • Prospective, Multicenter Cohort Study • n= 5,954 • Initial Purpose Is SAHS a risk factor for HTN & Cardiovascular Diseases? • Findings for our purposes: • No significant difference in the development of SAHS between COPD patients versus non-COPD patients Conclusion: • The coexistence of COPD & SAHS is due to CHANCE rather than rather than through a pathophysiologic linkage between the two conditions

  6. Overlap Syndrome • Clinical Features • Principles of Treatment

  7. CLINICAL FEATURES of Overlap Syndrome Quality of Sleep • COPD patients in the ABSENCE of SAHS: • Sleep was “Minimally Perturbed” (SHHS) • “Overlap Syndrome” patients (Sander et al.): • ↓ TOTAL Sleep Time • ↓ Sleep EFFICIENCY • ↑ Arousal Index Conclusion: The QUALITY of sleep in COPD patients is influenced by the presence of SAHS but NOT by the severity of airway obstruction

  8. CLINICAL FEATURES of Overlap Syndrome Severity of Respiratory Events • ↑ Nocturnal Hypoxemia • Sanders et al. • Endpoint: • Oxyhemoglobin saturation <85% for >5% of total sleep time • Results: • 20-fold increase in SAHS patients • 30-fold increase in Overlap Syndrome patients

  9. CLINICAL FEATURES of Overlap Syndrome Pulmonary Hypertension • ↑ Risk for Pulmonary Hypertension • Chaouat et al. • [COPD + SAHS] > SAHS alone • ↑ Risk in [Mild-Moderate COPD + SAHS] • Contrast to uncomplicated COPD Pulmonary HTN typically only seen in SEVERE COPD

  10. TREATMENT of Overlap Syndrome • 1st Line: • Nasal Continuous Positive Airway Pressure (nCPAP) • IF Mean Nocturnal SaO2 during NCPAP is <90%: • Supplemental O2 (1.5 – 3.0 L/min) • 2nd Line: • Bi-level Positive Airway Pressure (biPAP)

  11. TREATMENT of Overlap Syndrome • nCPAP vs. biPAP • There is currently NO outcome-evidence for the use of nCPAP or biPAP in patients with Overlap Syndrome • Why nCPAP over biPAP? • Strong evidence for the suppression of apneas, hypopneas and sleep-related hypoxemia in SAHS patients treated with nCPAP • Limited evidence for use of biPAP in COPD patients

  12. TREATMENT of SEVERE Overlap Syndrome • “Severe” Overlap Syndrome: • Daytime Hypoxemia PaO2 < 55-60 mmHg • Treatment: • Long-Term Oxygen Therapy (LTOT) + nPAP or biPAP

  13. Overlap Syndrome Take Home • COPD ≠ ↑Risk for SAHS • SAHS ≠ ↑Risk for COPD • [COPD + SAHS] = • ↓ Quality of Sleep • ↑ Nocturnal Hypoexmia • ↑ Risk for Pulmonary HTN • 1st Line Therapy = nPAP • 2nd Line= biPAP • Severe: LTOT + nPAP or biPAP

  14. QUESTIONS?

  15. References Chaouat A, Weitzenblum E, Krieger J, Ifoundza T, Oswald M, Kessler R. Association of chronic obstructive pulmonary disease and sleep apnea syndrome. Am Rev Respir Dis 1995;151:82–86. FlenleyDC. Sleep in chronic obstructive lung disease. Clin Chest Med 1985;6:51–61. Sanders MH, Newman AB, Haggerty CL, Redline S, Lebowitz M, Samet J, O'Connor GT, Punjabi NM, Shahar E for the Sleep Heart Health Study. Sleep and sleep-disordered breathing in adults with predominantly mild obstructive airway disease. Am J RespirCrit Care Med 2003;167:7–14. Weitzenblum, Emmanuel, Ari Chaouat, Romain Kessler, and MatthieuCanuet. "Overlap Syndrome: Obstructive Sleep Apnea in Patients with Chronic Obstructive Pulmonary Disease." Proceedings of the American Thoracic Society. 5.2 (2008): n. page. Web. 7 Oct. 2013. <http://www.atsjournals.org/doi/full/10.1513/pats.200706-077MG#.UlHsMtKPOeg>.

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