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Chronic obstructive pulmonary disease (COPD) and sleep apnea- this term is generally limited to the association of SAHS and
hypopnea syndrome (SAHS) are both common diseases affecting COPD.
respectively 10 and 5% of the adult population over 40 years of age, COPD is presently defined by the presence of an obstructive
and their coexistence, which is denominated overlap syndrome, can ventilatory defect characterized by an FEV1/FVC ratio less than
be expected to occur in about 0.5% of this population. A recent 70% in patients not exhibiting any other chronic respiratory
epidemiologic study has shown that the prevalence of SAHS is not disease (6). There is presently no standardized definition of
higher in COPD than in the general population, and that the SAHS. Generally, both a given level of respiratory disturbance
coexistence of the two conditions is due to chance and not through index or apnea-hypopnea index (> 10/h, > 15/h, etc.) and the
a pathophysiologic linkage between these two diseases. Patients
presence of symptoms (daytime sleepiness, poor quality of sleep,
with overlap have a more important sleep-related O2 desaturation
etc.) are required (7).
than do patients with COPD with the same degree of bronchial
obstruction. They have an increased risk of developing hypercapnic
respiratory insufficiency and pulmonary hypertension when com- PREVALENCE OF THE OVERLAP SYNDROME: IS SAHS
pared with patients with SAHS alone and with patients with ‘‘usual’’ MORE PREVALENT IN COPD THAN IN THE
COPD. In patients with overlap, hypoxemia, hypercapnia, and
GENERAL POPULATION?
pulmonary hypertension can be observed in the presence of mild
to moderate bronchial obstruction, which is different from ‘‘usual’’ Previous studies have suggested that the prevalence of SAHS
COPD. Therapy of the overlap syndrome consists of nasal continuous in patients with COPD, and of COPD in patients with SAHS,
positive airway pressure or nocturnal noninvasive ventilation (NIV), was high (2, 3, 8, 9)—sometimes unexpectedly high (2). The
with or without associated nocturnal O2. Patients who are markedly earliest report suffered from methodologic biases, since the 26
hypoxemic during daytime (PaO2 , 55–60 mm Hg) should be given patients with COPD investigated by Guilleminault and co-
conventional long-term O2 therapy in addition to nocturnal ventila- workers (2) had been in fact referred to a sleep clinic because
tion.
they complained of excessive daytime somnolence. This prob-
Keywords: chronic obstructive pulmonary disease; sleep apnea-hypopnea ably explains why sleep apneas were found in as many as 22/26
syndrome; overlap syndrome; noninvasive ventilation; nasal continuous patients. In studies by Bradley and colleagues (8, 9) and by
positive airway pressure Chaouat and coworkers (3) in which consecutive patients with
SAHS were investigated (n 5 50 and 265, respectively) the
Both chronic obstructive pulmonary disease (COPD) and sleep prevalence of an associated COPD, defined by the presence of
apnea-hypopnea syndrome (SAHS) are common diseases, and bronchial obstruction (either FEV1/FVC , 70% [8, 9] or FEV1/
many individuals would be expected to have both conditions by VC , 60% [3]) was, respectively, of 14% (9) and 11% (3). These
chance alone (1). It has been believed that the presence of figures were considered as high, suggesting that the prevalence
COPD could predispose to the development of SAHS (2), since of COPD in SAHS exceeded that observed in the general pop-
the two conditions share some etiologic factors such as tobacco ulation (3), but it must be underlined that at that time there
smoking. In fact, this remained an unresolved question (3) up to were very few reliable epidemiologic studies about the preva-
very recent years. In 2003 the Sleep Heart Health Study (SHHS) lence of COPD in the general population (10, 11). We presently
provided us with solid epidemiologic data about the coexistence know that the prevalence of COPD, defined by an FEV1/FVC
of COPD and SAHS (4). ratio less than 70% (GOLD stages I–IV [12]) is over 10% in
adults 40 years of age or older, and may exceed 20% (13–16).
DEFINITIONS The 265 patients with SAHS investigated by Chaouat and
colleagues (3) had a mean age of 54 6 10 years; 92% were
The combination of chronic obstructive pulmonary disease and males, and 66% were current smokers or ex-smokers. In
sleep apnea-hypopnea syndrome has been denominated ‘‘over- such a cohort a prevalence of COPD greater than 10% may
lap syndrome’’ by the late David Flenley (5). In his opinion be expected. Thirty out of 265 patients had COPD (3). Ac-
the term ‘‘overlap syndrome’’ could apply as well to the co- cordingly, it does not appear that the prevalence of COPD is
existence of SAHS and any chronic respiratory disease such as increased in patients with SAHS, when compared with the
idiopathic pulmonary fibrosis or cystic fibrosis (5), but the use of general population.
A putative association between SAHS and COPD could be
explained by the fact that the two conditions are favored by
a common etiologic factor, namely smoking. In fact, if the role
(Received in original form July 27, 2007; accepted in final form September 6, 2007)
of smoking is well established in COPD (6, 17), on the contrary
Correspondence and requests for reprints should be addressed to Emmanuel smoking is not presently considered as a documented risk factor
Weitzenblum, Professor of Medicine and Pulmonology, Hôpital de Hautepierre,
for SAHS, even if earlier studies (18) have suggested that
67098 Strasbourg, France. E-mail: emmanuel.weitzenblum@chru-strasbourg.fr
smoking could favor the occurrence of obstructive sleep apneas.
Proc Am Thorac Soc Vol 5. pp 237–241, 2008
DOI: 10.1513/pats.200706-077MG The only way to assess the prevalence of SAHS in COPD,
Internet address: www.atsjournals.org and to confirm whether this prevalence is higher or not than in
238 PROCEEDINGS OF THE AMERICAN THORACIC SOCIETY VOL 5 2008
the general population, is to undertake a large epidemiologic and vice versa. If the overlap syndrome is observed in a relatively
study. It should be emphasized that earlier studies on the over- high number of subjects (or patients), it is simply because COPD
lap syndrome (2, 3, 8, 9) have evaluated relatively small sam- and SAHS are both frequent conditions. If COPD is present in
ples and have included patients referred to Sleep Laboratories about 10% of the adult population 40 years of age or older
or Respiratory Disease Clinics, which results in a selection bias (13–15), and if the prevalence of SAHS in the same population
(4). The Sleep Heart Health Study (SHHS) is a prospective is in the range of 5 to 10% (21–24), overlap syndrome can be
multicenter cohort study that was designed to assess whether expected to be present in 0.5 to 1% of the population over 40
SAHS is a risk factor for hypertension and cardiovascular dis- years of age, which is a far from being negligible.
eases (19).
It is the largest study to date but it must be underlined that it
focused on a population enriched for cardiovascular risk profiles CLINICAL AND PULMONARY FUNCTION FEATURES
(including smoking). IN THE OVERLAP SYNDROME
Participants were recruited from ongoing cohort studies.
Quality of Sleep
They were at least 40 years old and had not received positive
airway pressure treatment for sleep apnea nor supplemental Many patients with COPD complain of poor-quality sleep, and
oxygen. They underwent unattended home polysomnography, objective evidence of disturbed sleep in COPD has been dem-
and spirometry was performed in all subjects (4). A total of onstrated by adequate EEG studies (25–29): sleep efficiency is
5,954 participants had complete spirometric data. Obstructive reduced, sleep onset is delayed, total sleep time is reduced, and
airway disease (OAD), which is synonymous of COPD, was periods of wakefulness are frequent and sometimes prolonged.
defined by an FEV1/FVC ratio less than 70% (20), which is in The causes of this poor-quality sleep are probably multifactorial
agreement with the present consensual definition of COPD (6). and include nocturnal cough, nocturnal dyspnea, use of drugs,
The main results of the SHHS are the following (4): the and the effects of ageing on sleep. In fact, these earlier studies
average FEV1/FVC of the cohort was 75.5 6 (SD) 7.9%. Subjects (25–29) have included patients with severe COPD with marked
with OAD(n 5 1,138, 19%) had a mean FEV1/FVC of 63.8 6 daytime hypoxemia. On the other hand, the SHHS (4) men-
6.6%, and those without OAD (n 5 4,816, 81%) had a mean tioned above, where 1,138 participants with mild COPD were
FEV1/FVC of 78.3 6 5.3%. Only a small number of participants investigated, has shown that in the absence of sleep apnea, sleep
(n 5 226, 3.8%) had an FEV1/FVC ratio less than 60%. The was minimally perturbed. No significant differences were ob-
respiratory disturbance index (RDI), that is, the average number served in sleep architecture in the subjects with the lowest com-
of apneas plus hypopneas per hour of sleep, was not higher in pared with the highest FEV1 quartile (4). Thus, COPD per se
subjects with OAD than in subjects without OAD. On the con- does not affect the quality of sleep. Sanders and colleagues
trary, participants with OAD had significantly lower mean and (4) have observed that subjects with overlap, compared with
median RDI than those without OAD (4) (Table 1). However, subjects who had only obstructive airway disease, had higher
after stratification by BMI quartile, RDI values were similar in Epworth sleepiness scores, lower total sleep time, lower sleep
the participants with and without OAD (4). efficiency, and higher arousal index. Only small differences
Thus, the prevalence of SAHS, defined either as an RDI were found between subjects with SAHS alone and those with
greater than 10 or greater than 15, is not greater in subjects with both disorders (subjects with overlap) (4). Thus, the quality of
COPD than in those without COPD among the general pop- sleep in COPD is influenced by the presence of SAHS but not
ulation. It ensues that the coexistence of COPD and SAHS is by the severity of airway obstruction (4).
due to chance rather than through a pathophysiologic linkage
between the two conditions (4). Severity of Respiratory Events and of Nocturnal Desaturation
The very low percentage of subjects with severe COPD may
limit the bearing of these results, which cannot be automatically Having prospectively investigated a series of 265 patients who
transposed to patients with advanced COPD. Nevertheless, the were selected on the basis of a confirmed diagnosis of SAHS
findings of Sanders and coworkers (4) do not support the hypoth- (apnea-hypopnea index . 20/h), Chaouat and coworkers (3)
esis that the presence of COPD favors the coexistence of SAHS have found an obstructive spirographic pattern (FEV1/VC ratio
< 60%) in 30/265 patients. These patients with overlap did not
differ from the remainder by their apnea index or apnea-
hypopnea index (Table 2), but nocturnal hypoxemia was more
TABLE 1. RESPIRATORY DISTURBANCE INDEX ACCORDING TO THE
PRESENCE OR NOT OF OBSTRUCTIVE PULMONARY DISEASE
Participants Participants TABLE 2. APNEAS, HYPOPNEAS, AND NOCTURNAL OXYGEN
without COPD with COPD SATURATION IN A SERIES OF 265 CONSECUTIVE PATIENTS
(FEV1/FVC > 70%) (FEV1/FVC , 70%) WITH SAHS: COMPARISON OF PATIENTS WITH SAHS ALONE
Variables (N 5 4,816) (N 5 1,138) (N5235) TO PATIENTS WITH OVERLAP (SAHS 1 COPD)
RDI: mean value 6 SD 9.13 6 12.59 7.49 6 11.87* Group as Patients with Patients with t test (overlap
RDI: median value (interquartile a Whole overlap SAHS Alone vs. SAHS
range) 4.51 (1.36, 11.59) 3.51 (1.35, 8.81)† Variables (n 5 265) (n 5 30) (n 5 235) Alone)
Participants with RDI . 10/h (%) 28.86 22.32*
Participants with RDI . 15/h (%) 18.63 13.97‡ AI, events/h 59 6 38 64 6 41 59 6 38 NS
RDI, events/h 77 6 33 89 6 37 76 6 32 NS
Definition of abbreviations: COPD 5 chronic obstructive pulmonary disease; TSA/TST, % 24 6 17 22 6 15 24 6 18 NS
RDI 5 respiratory disturbance index (events/h) (RDI is equivalent to apnea- M SaO2, % 91 6 4 89 6 4 91 6 4 p , 0.05
hypopnea index).
Results of the Sleep Heart Health Study (SHHS). Adapted by permission from Definition of abbreviations: AI 5 apnea index; M SaO2 5 mean nocturnal oxygen
Reference 4. transcutaneous saturation; RDI 5 respiratory disturbance index (5 apnea-
* P , 0.0001. hypopnea index); SAHS 5 sleep apnea-hypopnea syndrome; TSA/TST 5 time
†
P , 0.001. spent in apnea/total sleep time.
‡
P , 0.0002. Data are expressed as means 6 SD. Adapted by permission from Reference 3.
Weitzenblum, Chaouat, Kessler, et al.: Association of COPD and Sleep Apnea 239
important in patients with overlap than in patients with SAHS alone (Table 3). In the study by Chaouat and colleagues (3),
alone (P , 0.05). The average FEV1/VC of the 30 overlap 17/30 (57%) patients with overlap had a PaO2 less than or equal
patients was 50 6 6% (Table 3) (3), which is lower than the to 65 mm Hg versus 54/235 (23%) of patients with SAHS alone
average FEV1/FVC of 63.8 6 6.6% in the SHHS (4), a differ- (P , 0.001); 8/30 (27%) patients with overlap were hypercapnic
ence that can be explained by the fact that Chaouat and col- (PaCO2 > 45 mm Hg) versus 19/235 (8%) patients with SAHS
leagues (3) have investigated consecutive patients, whereas the alone (P , 0.05) (3). Of interest, these arterial blood gases re-
SHHS (4) has enrolled participants from the general popula- sults are very similar to those of Alford and coworkers (PaO2 5
tion. In spite of these differences, the SHHS (4) has also clearly 65 6 6.8 mm Hg, PaCO2 5 45.2 6 6.6 mm Hg) in their 20 pa-
demonstrated that subjects with both SAHS and COPD had tients with overlap whose bronchial obstruction was less pro-
greater sleep desaturation than those with only one disorder. nounced) (31).
After adjusting for age, sex, height, race, smoking status, and Hypoxemia and hypercapnia are more severe in patients
awake SpO2, the OR for oxyhemoglobin saturation below levels with obesity-hypoventilation than in patients with overlap
of 90 and 85% for more than 5% of total sleep time was 20-fold (Table 3), all patients having been investigated in a stable state
greater in participants with SAHS alone compared with those of the disease, several weeks after any exacerbation (30).
who had neither disorder and 30-fold greater in participants
with both disorders (subjects with overlap) (4). Pulmonary Hypertension
Consequently the risk of significant nocturnal desaturation is Patients with overlap are at risk of developing pulmonary
clear in patients who exhibit some degree of daytime hypox- hypertension (PH) even though their obstructive defect is not
emia, which is the case of the patients with overlap investigated severe. Chaouat and colleagues (3) have observed that among
by Chaouat and coworkers (3), but is also present in subjects the 26 patients with overlap who underwent right heart cathe-
with less severe overlap, as those recruited in the SHHS (4). terization, 11 had PH defined by a mean pulmonary artery pres-
Pulmonary Function and Arterial Blood Gases
sure (Ppa) greater than 20 mm Hg (Table 4). The prevalence of
PH was of 36% in patients with overlap, much higher than in
The results of spirography and arterial blood gases in a series of ‘‘usual’’ SAHS (19/181 5 9%), but somewhat lower than in the
30 patients with overlap (3) are given in Table 3. They are obesity-hypoventilation syndrome (Table 4) (30).
compared with those of patients with SAHS alone (3) and also Patients with overlap can develop PH even if they do not
to a series of patients with obesity-hypoventilation (30). As exhibit a marked degree of bronchial obstruction. In ‘‘usual’’
mentioned above, ‘‘patients’’ with overlap have lower pulmo- COPD, PH is generally observed in the case of severe bronchial
nary volumes and lower FEV1/VC ratio than do ‘‘subjects’’ with obstruction (FEV1 , 50% of the predicted value, and generally
overlap enrolled in cohort studies like the SHHS (4), and these < 1,000 ml) leading to significant hypoxemia. This discordance
differences might be explained by the different ways of re- has been emphasized by several authors (2, 3, 8, 9, 31–35). The
cruitment. On the other hand, the 20 patients with overlap hypoxemic–hypercapnic SAHS investigated by Bradley and
investigated by Alford and colleagues (31) were hospitalized colleagues (8, 9) exhibited cor pulmonale. The subjects from
and had an average FEV1/FVC of 63.7 6 10.9%, which is very that study were patients with overlap, but their average FEV1
similar to the average value of the SHHS participants exhibiting (2.0 6 0.31 l) and FEV1/FVC (59 6 5%) did not indicate severe
an OAD (63.8 6 6.6%). bronchial obstruction. Similarly, the FEV1/FVC of the patients
By definition, patients with overlap have an obstructive with overlap investigated by Fletcher and coworkers (34) was
ventilatory pattern that is most often mild to moderate, with close to 60%, which contrasted with marked hypoxemia and
an average FEV1 of 1,580 6 560 ml (52 6 15% of the predicted PH. This can be explained by the synergistic effects of the
value) in the series of Chaouat and coworkers (3) (Table 3). diseases on gas exchange and pulmonary hemodynamics (3, 32,
Total lung capacity ranges within normal limits (no static 34, 35).
hyperinflation). In patients with COPD, PH is generally observed when
The coexistence of COPD and SAHS favors the presence of daytime PaO2 is less than 55 to 60 mm Hg (36). The average day-
hypoxemia, which is rarely observed in patients with SAHS time PaO2 of the patients with overlap in the study by Chaouat
and colleagues (3) was higher (66 6 10 mm Hg) (Table 3) and
only 8/30 had a PaO2 less than 60 mm Hg. It must be kept in
TABLE 3. PULMONARY FUNCTION DATA AND ARTERIAL BLOOD
mind that if the daytime PaO2 of these patients is about 65 mm
GASES IN PATIENTS WITH OVERLAP COMPARED WITH
PATIENTS WITH SAHS ALONE AND WITH PATIENTS WITH Hg, the mean PaO2 during sleep is certainly lower because of
THE OBESITY-HYPOVENTILATION SYNDROME
SAHS Alone TABLE 4. PULMONARY HEMODYNAMICS IN PATIENTS WITH
OHS SAHS Alone Overlap versus overlap OVERLAP COMPARED WITH PATIENTS WITH SAHS ALONE
Variables (n 5 34) (n 5 235) (n 5 30) (P Value) AND WITH PATIENTS WITH THE OBESITY-HYPOVENTILATION
SYNDROME
Age, yr 61 6 11 53 6 10 58 6 9 , 0.05
BMI, kg/m2 40 6 8 32 6 6 31 6 5 NS OHS SAHS Alone Overlap SAHS Alone versus
VC, % predicted 79 6 16 91 6 15 77 6 20 , 0.001 Variables (n 5 27) (n 5 180) (n 5 26) overlap (P Value)
FEV1, liters 1.85 6 0.64 2.87 6 0.74 1.58 6 0.56 , 0.001
FEV1, % predicted 70 6 17 88 6 17 52 6 15 , 0.001 Ppa, mm Hg 23 6 10 15 6 5 20 6 6 , 0.001
FEV1/VC, % 69 6 7 75 6 10 50 6 6 , 0.001 PVR, mm Hg/L/min 4.0 6 1.5 2.7 6 1.2 3.6 6 1.8 , 0.002
TLC, % predicted 78 6 11 86 6 11 88 6 13 NS Cardiac output, L/min 6.2 6 18 5.9 6 1.6 5.9 6 1.6 NS
PaO2, mm Hg 59 6 7 75 6 10 66 6 10 , 0.001 PH, n (%) 17 (58) 19 (9) 11 (36) , 0.001
PaCO2, mm Hg 49 6 3 38 6 4 42 6 6 , 0.001
Definition of abbreviations: OHS 5 obesity-hypoventilation syndrome; Ppa 5
Definition of abbreviations: BMI 5 body mass index; FEV1 5 forced expiratory pulmonary artery mean pressure; PVR 5 pulmonary vascular resistance; PH 5
volume in one second; OHS 5 obesity-hypoventilation syndrome; SAHS 5 sleep pulmonary hypertension (defined by a Ppa . 20 mm Hg); SAHS 5 sleep apnea-
apnea-hypopnea-syndrome; TLC 5 total lung capacity; VC 5 vital capacity. hypopnea syndrome.
Data are expressed as means 6 SD. Adapted by permission from References 3 Data are expressed as means 6 SD. Adapted by permission from References 3
and 30. and 30.
240 PROCEEDINGS OF THE AMERICAN THORACIC SOCIETY VOL 5 2008
the repetition of apneas and hypopneas (the time spent in ap- who are markedly hypoxemic during daytime (PaO2 , 55–
nea represented 22 6 15% of the total sleep time in the over- 60 mm Hg) should receive conventional LTOT in addition to
lap group [3]). Thus, the combination of marked nocturnal nocturnal ventilation.
hypoxemia with a mild to moderate diurnal hypoxemia could
Conflict of Interest Statement: None of the authors has a financial relationship
explain the occurrence of pulmonary hypertension. with a commercial entity that has an interest in the subject of this manuscript.
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