Sleep and chronic pulmonary disorders

Rossana Terlizzi MD (Dr. Terlizzi of University of Bologna has no relevant financial relationships to disclose.)
Pietro Cortelli MD PhD (Dr. Cortelli of the University of Bologna has no relevant financial relationships to disclose.)
Antonio Culebras MD, editor. (Dr. Culebras of SUNY Upstate Medical University has no relevant financial relationships to disclose.)
Originally released November 22, 1993; last updated October 30, 2015; expires October 30, 2018

This article includes discussion of sleep and chronic pulmonary disorders, sleep disorders in chronic obstructive pulmonary disease, sleep disorders in asthma, and sleep disorders in pulmonary fibrosis. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.

Overview

Chronic pulmonary disorders are frequently associated with sleep-related abnormalities. Presence of these comorbidities contributes to worsen the poor quality of life in these patients and increases the risk of several other adverse health outcomes including higher mortality. The authors explain control of breathing during sleep in patients with chronic lung disorders, particularly chronic obstructive pulmonary disease, and discuss the impact of chronic lung disorders on nocturnal gas exchanges and sleep disturbances. The clinical importance of the overlap syndrome (association between chronic obstructive pulmonary disease and obstructive sleep apnea syndrome) is discussed. In addition, the authors provide a review of consensus guidelines in the diagnosis and treatment of sleep disorders associated with these common conditions.

Key points

 

• Patients with chronic obstructive pulmonary disease frequently complain of sleep-related symptoms like unrefreshing sleep, insomnia, fatigue, and diurnal sleepiness.

 

• Studies during sleep show that in chronic obstructive pulmonary disease, patients' oxyhemoglobin saturation is reduced from waking levels and sleep continuity is disrupted by arousals related to hypoventilation and hypoxemia.

 

• Management of sleep problems in chronic obstructive pulmonary disease should be primarily focused on optimizing the patient's overall respiratory condition through correct treatment to ensure that poor symptom control is not the main cause of sleep disturbances.

 

• Long-term continuous oxygen therapy should be introduced to improve survival, sleep, and quality of life only in severe forms of chronic obstructive pulmonary disease with daytime resting PaO2 equal or less than 55 mm Hg.

 

• Sleep studies are usually not indicated in patients with chronic obstructive pulmonary disease except in special circumstances like the clinical suspicion of coexisting obstructive sleep apnea syndrome, as the presence of both conditions has negative implications with respect to prognosis.

Historical note and terminology

The modern study of breathing-related sleep disorders began with the demonstration that during sleep arterial pCO2 increases and pO2 decreases in normal subjects (Robin et al 1958). Worsening hypoxemia during sleep in patients with chronic obstructive pulmonary disease has been documented since 1962 (Trask and Cree 1962), but the first polysomnographic studies were performed more than 10 years later using intermittent measurements of arterial blood gases (Koo et al 1975). Following the development of reliable oximeters, Flick and Block demonstrated the characteristic pattern of oxyhemoglobin desaturation in chronic obstructive pulmonary disease (Flick and Block 1977), and other investigators related the severe desaturations to REM sleep (Coccagna and Lugaresi 1978).

The modern study of nocturnal asthma began with the demonstration in asthma of an abnormal decrease of expiratory lung function during the sleep period (Clark and Hetzel 1977). Subsequent works have investigated the mechanisms of these changes and the effect of treatments (Greenberg and Cohen 2012).

Lung diseases are classified as obstructive or restrictive based on the pattern of ventilatory impairment. In the International Classification of Sleep Disorders (American Academy of Sleep Medicine 2014), sleep disorders associated with chronic lung disorders are classified in the field “Sleep related breathing disorders” under the chapters “Sleep related hypoxemia disorder” and “Sleep related hypoventilation due to a medical disorder. The majority of studies address sleep disorders in the common obstructive conditions, such as chronic obstructive pulmonary disease (COPD) and asthma. The limited data available about restrictive lung diseases mainly address idiopathic pulmonary fibrosis (IPF).

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