This document discusses sleep-related breathing disorders in a patient with COPD. It outlines the results of a sleep study showing an AHI of 21.4/hr and ODI of 23/hr, indicating obstructive sleep apnea. It then discusses several types of sleep disorders that can occur in COPD patients, including obstructive sleep apnea, nocturnal hypoxemia, sleep-related hypoventilation, and central sleep apnea. The treatment options discussed include CPAP, NIV, and nocturnal oxygen therapy, though the benefits are unclear.

1. Sleep Time!
Umair Falak

2. History
• 56 year old
• COPD on triple therapy ,
• High BMI( 44.5 kg/m2) , 35 kg gain
• IHD –PCI , Hypertension, Echo- normal lv function(2017)
• Fibromyalgia on Tramadol prn
• Breathless – 5 yards or so , house bound , MRCD score 5
• Ex-smoker
• No past history of acute hypercapnic failure or NIV use

3. Sleep
• Night time arousals , snoring and Excessive daytime sleepiness
• No witnessed apneas
• Oxygen saturation on room air- 94%
• Bicarbonate 26 mmhg
• Ph- 7.40 , Pco2- 4.9 Kpa , Po2-9.3 Kpa, Bicarbonate- 23.6 mmhg ,
Sats-96.1%

10. Sleep Study ?
• Home overnight Oximetry ->
saturation and pulse
central versus obstructive apnoea
unreliable in COPD other
respiratory diseases
• TOSCA Study -> TCCO2 , oxygen
saturation , pulse but notorious
• Apnea link Test
• Polysomnography -> gold
standard

12. Diagnosis –Number 5
• Apnoea-hypopnea index (AHI) > 5/hr
• ODI(oxygen desaturation index) >5/hr
Drop in oxygen saturation of 4% or more
• Hypopnea – decrease of flow of 30% for 10 secs or 4% drop in
saturation
• Apnoea- 90% or more decrease in flow for 10 secs
• At least 4 hours of recordings

13. AHI – 21.4/hr
ODI-23.0/hr
TSTT<90% -
99%
Snore-6161

17. Overlap Syndrome- COPD & OSA
• True overlap ?
• 10-30% of COPD pts , underdiagnosed
• FEV1 ratio < 65%
• Current smoker
• Daytime hypercapnia
• Worse prognosis then either alone
• More severe nocturnal hypoxemia , PH , arrhythmias
Global Initiative for Chronic Obstructive Lung Disease (GOLD). Global Strategy for the Diagnosis, Management and
Prevention of Chronic Obstructive Pulmonary Disease: 2020 Report. www.goldcopd.org (Accessed on March 04,
2020).

18. Pathogenesis
• V/q mismatching worse during sleep
• Sleep hypoventilation
1. Compensatory mechanism stop
2. Sleep Blunts Ventilatory response & drive
• Dilator muscles loose tone during sleep  Inspiratory flow reduced
 expiration time decreased
• Increased lung volumes in emphysema  protective

19. When to worry about it
• Symptoms of EDS , apneoic attacks , snoring ,High ESS
• Obesity, Usual neck circumference , facial features
• Opioids use & others
• Heart Failure ,Atrial fibrillation , Stroke , ESRD
• Borderline daytime oxygen sats( < 93%)
• Polycythaemia
• Pulmonary Hypertension
• Overnight oximetry not sufficient

20. Treatment
• Weight reduction , Alcohol , Medicines
• Smoking cessation
• CPAP  improves mortality clear benefit unlike
• NIV (CPAP > 15 cmH20) – evidence ?
• Oxygen never alone
Marin JM, Soriano JB, Carrizo SJ, Boldova A, Celli BR. Outcomes in patients with chronic obstructive
pulmonary disease and obstructive sleep apnea: the overlap syndrome. Am J Respir Crit Care Med2010;
182(3): 325-31.

21. COPD sleep related Breathing disorders
• OSA (Overlap syndrome )
• Nocturnal hypoxemia
• Sleep Related Hypoventilation
• Central sleep apnea

22. 2nd patient
• 49 yr old
• EDS (ESS 20) with snoring and apnoeic episodes
• COPD
• Smoker
• BMI 29.6 kg/m2

23. AHI – 5.9/hr
ODI – 45.6/hr
Snores – 107
TSTT <90% - 94%

26. Nocturnal hypoxemia in COPD patients
• Non specific symptoms
• FEV1 ratio < 65%
• Borderline day saturation (91-95% ) or hypoxemic
• Worse survival
• INOX trial isolated nocturnal hypoxemia –premise of PH,Rt HF
• If they fulfil criteria for LTOT give 24 hours oxygen
Lewis CA, Fergusson W, Eaton T, Zeng I, Kolbe J. Isolated nocturnal desaturation in COPD: prevalence and impact on
quality of life and sleep. Thorax. 2009 Feb;64(2):133-8. doi: 10.1136/thx.2007.088930. Epub 2008 Apr 4. PMID:
18390630.

27. Nocturnal Oxygen therapy
• If the patient does not fulfil criteria for LTOT then
• No consistent survival advantage .(Evidence level 1+)
• Sleep quality no benefit. (Evidence level 1−)
• Not recommended in patients with COPD who have nocturnal
hypoxaemia but who fail to meet the criteria for LTOT. (Grade A)
• Other causes of nocturnal desaturation in COPD should be considered
Hardinge M, et all; British Thoracic Society Home Oxygen Guideline Development Group; British Thoracic Society
Standards of Care Committee. British Thoracic Society guidelines for home oxygen use in adults. Thorax. 2015
Jun;70 Suppl 1:i1-43. doi: 10.1136/thoraxjnl-2015-206865. PMID: 25870317.

29. Sleep related Hypoventilation
43% patients with daytime compensated hypercapnic COPD pts
Sleep study
• Total sleep time with saturations <90%  >30%
• Instead of characteristic saw tooth like desaturation prolonged
sustained hypoxemia for 5 minutes or more
• Low Mean saturation < 88% or less ( often <80% )
Limited data but Nocturnal NIV +/- oxygen in symptomatic pts with
daytime hypercapnia
CPAP Only night-time hypoventilation perhaps!!

30. Central Sleep Apnea
• Risk factor
• Unclear
• Optimise COPD
• CPAP trial with oxygen  different types do overlap

31. Conclusion
• Types of Sleep related breathing disorders in COPD
• Different types do overlap with each others difficult to separate them
• Overnight oximetry not much use
• Unclear benefits of treatment