Sleep profile and symptoms of sleep disorders in patients with stable mild to moderate chronic obstructive pulmonary disease

Effects of non-invasive ventilation on sleep in chronic hypercapnic respiratory failure

Chronic respiratory disease can exacerbate the normal physiological changes in ventilation observed in healthy individuals during sleep, leading to sleep-disordered breathing, nocturnal hypoventilation, sleep disruption and chronic respiratory failure. Therefore, patients with obesity, slowly and rapidly progressive neuromuscular disease and chronic obstructive airways disease report poor sleep quality. Non-invasive ventilation (NIV) is a complex intervention used to treat sleep-disordered breathing and nocturnal hypoventilation with overnight physiological studies demonstrating improvement in sleep-disordered breathing and nocturnal hypoventilation, and clinical trials demonstrating improved outcomes for patients. However, the impact on subjective and objective sleep quality is dependent on the tools used to measure sleep quality and the patient population. As home NIV becomes more commonly used, there is a need to conduct studies focused on sleep quality, and the relationship between sleep quality and health-related quality of life, in all patient groups, in order to allow the clinician to provide clear patient-centred information.

Creation of a shortened version of the Sleep Disorders Questionnaire (SDQ)

The 176-item Sleep Disorders Questionnaire (SDQ) was initially developed using canonical discriminant function analysis on 4 groups of sleep disorder patients, but it was never studied by factor analysis in its entirety. Several authors have criticized 2 of its subscales as being confounded with each other, and its narcolepsy scale as substantially over-diagnosing narcolepsy. This study describes its first exploratory factor analysis (EFA), the intent of which was to reassess item membership on the 4 existing subscales and to derive new scales to improve differential diagnosis between patient groups. It was also hoped that EFA could reduce the total number of questions, to increase speed of completion. The EFA was performed on the anonymized SDQ results from a retrospective review of the charts of 2131 persons from 7 sleep disorders clinics and research centers. Factors were assessed via scree plots and eigenvalues. The EFA identified four main factors: insomnia, daytime sleepiness, substance use, and sleep-disordered breathing. The insomnia factor had 3 subfactors: psychological symptoms of insomnia, subjective description of insomnia, and insomnia due to periodic limb movements. The sleepiness factor had two subfactors: daytime sleepiness and neurological symptoms of narcolepsy. The novel substance use factor was homogeneous, as was the sleep-disordered breathing factor. Importantly, the EFA reassigned items from the original SDQ's NAR, PSY, and PLM subscales to five of the new subscales. The Sleep Apnea (SA) subscale emerged mostly unchanged. The 7 resulting factors comprised only 66 items of the original 176-item SDQ. These results have allowed the creation of a new shorter questionnaire, to be called the SDQ-2. External validation of the SDQ-2 is currently underway. It will likely prove to be a superior differential diagnostic instrument for sleep disorders clinics, compared to the original SDQ.

Poor sleep is associated with deficits of attention in COPD patients

BACKGROUND

Poor sleep and attention deficits are common in COPD.

OBJECTIVES

To assess the relationship between self-reported poor sleep and attention deficits in COPD. We also studied the association between self-reported sleep and the attention tests with the objective characteristics of sleep.

METHODS

Fifty-nine COPD patients were prospectively studied. Self-reported sleep quality was assessed using the Pittsburgh sleep quality index (PSQI). Objective characteristics of sleep were assessed by actigraphy and polysomnography. Attention was evaluated with the Oxford sleep resistance test (OSLER) and the Psychomotor vigilance test (PVT).

RESULTS

28 (47 %) patients referred poor sleep (PSQI >5). In the OSLER test they showed earlier sleep onset than patients with good sleep, median (Interquartil range): 31.2 min (25.4-40) vs 40 min (28.5-40), p: 0.048. They also spent more time making errors: 4.5 % (0.6-7.6) of total test time vs 0.7 % (0.2-5.3), p: 0.048. In PVT, patients with poor sleep presented a greater dispersion of the reaction time values with a higher value in the slowest 10 % of the reactions, 828 (609-1667) msec. vs 708 (601-993) msec, p: 0.028. No association was found between self-reported poor sleep and objective sleep variables. We found no correlation between OSLER and PVT results and polysomnographic variables except between sleep efficiency and PVT response speed (β: 0.309, p: 0.018).

CONCLUSION

Self-reported poor sleep in COPD is associated with attention deficits. Sleep quality should be included in future studies of this facet of cognition in COPD, as well as to assess its potential usefulness as a therapeutic target.

Association Between Hypnotic Use and All-Cause Mortality in Patients with Chronic Obstructive Pulmonary Disease and Insomnia

Purpose

Hypnotics are commonly prescribed in patients with COPD to manage insomnia. Given the considerable risks associated with these drugs, the aim of the study was to evaluate the risk of all-cause mortality associated with hypnotics in a cohort of veterans with COPD presenting with insomnia.

Methods

We conducted a retrospective cohort study that used Veterans Health Administration Corporate Data Warehouse with data supplemented by linkage to Medicare, Medicaid, and National Death Index data from 2010 through 2019. The primary outcome was all-cause mortality. Analyses were conducted using propensity score 1:1 matching to balance baseline characteristics.

Results

Of the 5759 veterans with COPD (mean [SD] age, 71.7 [11.2]; 92% men), 3585 newly initiated hypnotic agents during the study period. During a mean follow-up of 7.4 (SD, 2.7) years, a total of 2301 deaths occurred, with 65.2 and 48.7 total deaths per 1000 person-years among hypnotic users and nonusers, respectively. After propensity matching, hypnotic use was associated with a 22% increased risk of mortality compared with hypnotic nonusers (hazard ratio [HR] 1.22; 95% confidence interval [CI],1.11-1.35). The benzodiazepine receptor agonists (BZRAs) group experienced a higher incidence rate of all-cause mortality compared to hypnotic nonusers (Incidence rate ratio [IRR] 1.27; 95% CI, 1.14-1.43). Conversely, the mortality rate of non-BZRA hypnotics decreased after the first 2 years and was not significantly different for hypnotic nonusers (IRR 1.04; 95% CI, 0.82-1.11).

Conclusion

Among patients with COPD and insomnia, treatment with hypnotics was associated with a higher risk of all-cause mortality. The association was observed in patients prescribed BZRAs. The risk of mortality for non-BZRAs moderated after the first 2 years, indicating a class effect.

Sleep Duration and Chronic Disease Among Older Native Hawaiians or Other Pacific Islanders and Asians: Analysis of the Behavioral Risk Factor Surveillance System

OBJECTIVES

Older adults are particularly vulnerable to unhealthy sleep. This study examines the relationship between sleep duration and chronic diseases among older Native Hawaiians or Other Pacific Islanders (NHOPIs) and identifies variations with older Asians.

METHODS

In this cross-sectional study, data were analyzed using the 2016 Behavioral Risk Factor Surveillance System. The total sample of adults 50 years and older included 1277 NHOPIs and 4655 Asians. Weighted, survey logistic regressions were employed to analyze the relationship between sleep duration (i.e., short, healthy, and long) and seven chronic diseases: coronary heart disease, stroke, heart attack/myocardial infarction, pre-diabetes, diabetes, chronic obstructive pulmonary disease, and depressive disorder. Sleep duration was categorized into short sleep (SS; ≤ 6 h), healthy sleep (7-8 h), and long sleep (LS; ≥ 9 h), with healthy sleep as the reference group.

RESULTS

Among NHOPIs, SS and LS were significantly related to stroke (OR 3.19, 95% CI: 1.35-7.53 for SS and OR 9.52, 95% CI: 2.99-30.34 for LS) and SS was associated with pre-diabetes (OR 2.22 CI: 1.07-4.59), after adjusting for all covariates. In contrast, Asians with SS and LS reported higher odds of depression (OR 2.40, 95% CI: 1.20-4.79 and OR 5.03, 95% CI: 1.57-16.13, respectively).

CONCLUSIONS

Findings suggest older NHOPIs with SS or LS experience worse health. NHOPIs and Asians varied on the relationship between sleep and chronic disease, underscoring the need to disaggregate Asian/NHOPI data to understand health disparities.

Impact of sleep chronotype on in-laboratory polysomnography parameters

Morningness-eveningness preference, also known as chronotype, is the tendency for a person to sleep during certain hours of the day and is broadly categorised into morning and evening types. In-laboratory polysomnography (iPSG) is the gold-standard to assess sleep, however, an individual's chronotype is not accounted for in current protocols, which may confound collected sleep data. The objective of our study was to assess if chronotype had an association with sleep physiology. Patients who completed the diagnostic iPSG and the Morningness-Eveningness Questionnaire (MEQ), which categorises patients into morning type, neither or evening type, were assessed. Multivariable linear regression models were used to assess if chronotype was associated with sleep quality, duration, and physiology during iPSG. The study sample included 2612 patients (mean age of 53.6 years, 48% male) recruited during 2010-2015. Morning type, compared with neither type, was significantly associated with an increase in total sleep time and rapid eye movement (REM) sleep, and a decrease in sleep onset latency and the arousal index. Evening type, compared with neither type, was significantly associated with a decrease in total sleep time, sleep efficiency, and REM sleep, and an increase in sleep onset latency and wake after sleep onset. Additionally, iPSG lights out time was significantly different between the different chronotypes. Overall, a morningness chronotype was associated with favourable sleep quality and duration while an eveningness chronotype was associated with reduced sleep quality. Our study quantifies the association of chronotype with iPSG metrics and suggests that laboratory protocols should consider chronotype in their evaluations.

Quality of life in patients with chronic respiratory failure on home mechanical ventilation

Home mechanical ventilation (HMV) is a treatment for chronic respiratory failure that has shown clinical and cost effectiveness in patients with underlying COPD, obesity-related respiratory failure and neuromuscular disease (NMD). By treating chronic respiratory failure with adequate adherence to HMV, improvement in patient-reported outcomes including health-related quality of life (HRQoL) have been evaluated using general and disease-specific quantitative, semi-qualitative and qualitative methods. However, the treatment response in terms of trajectory of change in HRQoL is not uniform across the restrictive and obstructive disease groups. In this review, the effect of HMV on HRQoL across the domains of symptom perception, physical wellbeing, mental wellbeing, anxiety, depression, self-efficacy and sleep quality in stable and post-acute COPD, rapidly progressive NMD (such as amyotrophic lateral sclerosis), inherited NMD (including Duchenne muscular dystrophy) and obesity-related respiratory failure will be discussed.

Association of self-reported sleep problems with morbidities and multimorbidities according to sex: National Health Survey 2019

OBJECTIVE

To evaluate the association between self-reported sleep problems and the presence of non-communicable diseases (NCDs) and multimorbidity, and whether these associations differ by sex.

METHODS

This is a cross sectional study performed with data from the Brazilian National Health Survey, 2019. Prevalence ratios between morbidities, the number of NCDs, and the self-report of sleep problems were estimated by Poisson regression with robust variance, according to sex.

RESULTS

This study analysed data from 85,531 Brazilians age ≥ 18 years. The self-reported sleep problems were associated with all the herein studied morbidities and multimorbidities. The prevalence of sleep problems was higher in those who stated one or two (PR = 2.37; 95%CI 2.22;2.54) and three or more NCDs (PR = 4.73; 95%CI 4.37;5.11). Prevalence ratios of the association with diabetes, lung disease, mental disease, renal disease and multimorbidities were higher among males.

CONCLUSION

NCDs significantly impacted sleep quality, with a particularly stronger association in both, males and females.

Sleep Deficiency, Sleep Apnea, and Chronic Lung Disease

With sleep occupying up to one-third of every adult's life, addressing sleep is essential to overall health. Sleep disturbance and deficiency are common in patients with chronic lung diseases and associated with worse clinical outcomes and poor quality of life. A detailed history incorporating nocturnal respiratory symptoms, symptoms of obstructive sleep apnea (OSA) and restless legs syndrome, symptoms of anxiety and depression, and medications is the first step in identifying and addressing the multiple factors often contributing to sleep deficiency in chronic lung disease. Additional research is needed to better understand the relationship between sleep deficiency and the spectrum of chronic lung diseases.

Sleep quality in COPD patients: correlation with disease severity and health status

Objective:

To evaluate clinical predictors of poor sleep quality in COPD patients with and without obstructive sleep apnea (OSA).

Methods:

Consecutive stable patients with COPD were evaluated for OSA by means of overnight polysomnography; for sleep quality by means of the Pittsburgh Sleep Quality Index (PSQI); and for disease impact by means of the COPD Assessment Test. COPD severity was graded in accordance with the 2020 GOLD guidelines. Predictors of poor sleep quality were evaluated by multivariate logistic regression analysis.

Results:

We studied 51 patients with COPD alone and 51 patients with COPD and OSA. Both groups had similar age (66.2 ± 9.2 years vs. 69.6 ± 10.7, p = 0.09) and airflow limitation (p = 0.37). Poor sleep quality was present in 74.8% of the study participants, with no significant difference between COPD patients with and without OSA regarding PSQI scores (p = 0.73). Polysomnography showed increased stage 1 non-rapid eye movement sleep and arousal index, as well as reduced sleep efficiency and stage 3 non-rapid eye movement sleep, in the group of patients with COPD and OSA (p < 0.05). Independent predictors of poor sleep quality were GOLD grade C/D COPD (OR = 6.4; 95% CI, 1.79-23.3; p < 0.01), a COPD Assessment Test score ≥ 10 (OR = 12.3; 95% CI, 4.1-36.5; p < 0.01), and lowest SaO₂ < 80% (p < 0.0001).

Conclusions:

Poor sleep quality is quite common in patients with COPD and is associated with severe COPD and poor health status, having a negative impact on overall quality of life. Despite changes in polysomnography, OSA appears to have no impact on subjective sleep quality in COPD patients.

Characteristics of the nocturnal desaturation waveform pattern of SpO2 in COPD patients: an observational study

BACKGROUND

Nocturnal desaturation is common in patients with chronic obstructive pulmonary disease (COPD) and impacts disease exacerbation and prognosis. In our previous study, we developed a diagnostic algorithm to classify nocturnal desaturation from SpO₂ waveform patterns based on data from patients receiving home oxygen therapy. In this study, we aimed to investigate nocturnal desaturation in patients with COPD based on SpO₂ waveform patterns and the associations between the waveforms and clinical data.

METHODS

We investigated patients diagnosed with COPD and measured SpO₂ and nasal airflow with a type 4 portable long-term recordable pulse oximeter. Then, we classified the SpO₂ waveforms with the algorithm and compared the clinical data.

RESULTS

One hundred fifty-three patients (136 male and 17 female) were analysed. One hundred twenty-eight of the 153 (83.7%) patients had nocturnal desaturation, with an intermittent pattern (70.6%), sustained pattern (13.1%) and periodic pattern (68.0%). Intriguingly, desaturation with an intermittent pattern was associated with the apnoea-hypopnea index obtained with the portable monitor, and desaturation with a sustained pattern was associated with the cumulative percentage of time at a SpO₂ below 90%.

CONCLUSIONS

We found that nocturnal desaturation was frequently observed in patients with COPD and could be classified into 3 types of waveform patterns.

Was Sleep a Problem for the Elderly During COVID-19?

Over the past few decades, the population of geriatrics has seen an exponential rise and it is well known that the prevalence of chronic diseases and other associated comorbidities is higher among them which in turn, has an established association with sleep disorders. During these unprecedented circumstances, geriatrics are predisposed to be at an increased risk of sleep disorders due to the social isolation and loneliness imposed on them by the lockdowns. The fact that older adults are at a greater risk of contracting the virus due to the presence of comorbidities and the high virulence adds on to the existing risk of sleep disturbances. A lack of sleep in these circumstances has the potential to add on to the vicious cycle of sleep disorders predisposed by chronic disease and vice versa. Mental health, sleep and the presence of comorbidities are closely interlinked and they often tend to overlap. Research in sleep has established insomnia to be the most commonly diagnosed sleep disorder affecting almost 50% of the older adults which can subsequently, elevate their risk of falls. This prevalence of sleep disorders is hypothesized to increase during the second wave of the COVID-19 pandemic and a good sleep routine needs to be advocated for to improve the quality of life of this population. However, scientific evidence concerning this is scarce and this review aims to highlight the significance of sleep and urges its readers to undertake studies that investigate the architecture of sleep amongst older adults during the pandemic.

Sleep quality and architecture in COPD: the relationship with lung function abnormalities

OBJECTIVE

Impaired respiratory mechanics and gas exchange may contribute to sleep disturbance in patients with COPD. We aimed to assess putative associations of different domains of lung function (airflow limitation, lung volumes, and gas exchange efficiency) with polysomnography (PSG)-derived parameters of sleep quality and architecture in COPD.

METHODS

We retrospectively assessed data from COPD 181 patients ≥ 40 years of age who underwent spirometry, plethysmography, and overnight PSG. Univariate and multivariate linear regression models predicted sleep efficiency (total sleep time/total recording time) and other PSG-derived parameters that reflect sleep quality.

RESULTS

The severity of COPD was widely distributed in the sample (post-bronchodilator FEV1 ranging from 25% to 128% of predicted): mild COPD (40.3%), moderate COPD (43.1%), and severe-very severe COPD (16.6%). PSG unveiled a high proportion of obstructive sleep apnea (64.1%) and significant nocturnal desaturation (mean pulse oximetry nadir = 82.2% ± 6.9%). After controlling for age, sex, BMI, apnea-hypopnea index, nocturnal desaturation, comorbidities, and psychotropic drug prescription, FEV1/FVC was associated with sleep efficiency (β = 25.366; R2 = 14%; p < 0.001), whereas DLCO predicted sleep onset latency (β = -0.314; R2 = 13%; p < 0.001) and rapid eye movement sleep time/total sleep time in % (β = 0.085; R2 = 15%; p = 0.001).

CONCLUSIONS

Pulmonary function variables reflecting severity of airflow and gas exchange impairment, adjusted for some potential confounders, were weakly related to PSG outcomes in COPD patients. The direct contribution of the pathophysiological hallmarks of COPD to objectively measured parameters of sleep quality seems to be less important than it was previously assumed.

Total Sleep Time in the Taiwan Obstructive Lung Disease Cohort

Patients with chronic obstructive pulmonary disease (COPD) have been reported to have poor sleep quality. However, total sleep time has not been evaluated in detail among patients with COPD. This retrospective, observational, multicenter research study was performed across six participating hospitals in Taiwan, with a total of 421 adult patients enrolled. Pulmonary function, the Modified British Medical Research Council Dyspnea Scale, the COPD Assessment Test and basic clinical data were assessed. The Pittsburgh Sleep Quality Index was also administered to patients, and the total sleep time was extracted for further analysis. The patients whose total sleep time was between 6 and 7 h had better pulmonary function, and the patients who slept less than 5 h had worse comorbidities. There was a significant higher total sleep time in Global Initiatives for Chronic Obstructive Lung Disease (GOLD) group B compared to GOLD group A. COPD patients who sleep between 5 and 6 h used fewer oral steroids and were less likely to use triple therapy (long-acting beta-agonist, long-acting muscarinic antagonist, inhaled cortical steroid). COPD patients sleeping from 5 to 7 h had better clinical features than those sleeping less than 5 h in terms of pulmonary function, comorbidities and medication usage.

Sleep features in Lymphangioleiomyomatosis and their relationship with disease severity: a pilot study

Lymphangioleiomyomatosis (LAM) is a rare pulmonary disease characterized by progressive airflow limitation. We conducted a pilot trial to investigate the incidence of sleep disorders, sleep quality and their relationship with disease severity. We performed pulmonary function tests, blood gas analysis, overnight 12-channels polysomnography and clinical assessments in 15 consecutive LAM patients. For statistics, p values < 0.05 were considered significant. Sleep efficiency (SE) was inversely correlated with RV/TLC (p = 0.035) and positively with daytime SpO2 (p = 0.010) and PaO2 (p = 0.011). Three cases had obstructive sleep apnea (OSA); seven patients (46.7%) showed a REMOSA. AHI_REM was correlated with FEV1% (r = 0.75, p = 0.003), TLC% (r = 0.57, p = 0.026), RV% (r = 0.8, p=<0.0001) and RV/TLC (r = 0.77, p = 0.001). No correlations were observed between anxiety/depression and SE, CAP rate, pulmonary function test variables and AHI_REM (p > 0.05). four subjects had nocturnal hypoxia (T90 ≥ 1% of TST) showing lower values of DLCO%, daytime SpO2%, PaO2, FEV1% and a higher value of VR/TLC comparing with the subgroup with normal T90 (p < 0.05). This pilot study shows that sleep alterations could be frequent in LAM and associated to disease severity. Nocturnal hypoxemia and SE were related to lung function impairment. A dysregulation of sleep seems to involve exclusively REM phase, while NREM appears to be preserved. This phenomenon might be linked to the pathophysiology of disease: our study, even with the limits of the small sample size, showed that the presence of REMOSA is related to the disease severity, in particular to the degree of airflow limitation and hyperinflation. More studies are needed to assess this topic.

Sleep in hospitalized patients with chronic obstructive pulmonary disease: an observational study

STUDY OBJECTIVES

The aim of this study was to compare the risk of undiagnosed sleep disorders among medical patients with chronic obstructive pulmonary disease (COPD) compared with those without COPD.

METHODS

In a prospective cohort study, hospitalized medical ward patients without a known sleep disorder were screened, using validated questionnaires, for sleep disorders, such as obstructive sleep apnea and insomnia. Daily sleep duration and efficiency in the hospital were measured via wrist actigraphy. Participants were classified into two groups: those with a primary or secondary diagnosis of COPD and those without a history of COPD diagnosis. Sleep outcomes were compared by COPD diagnosis.

RESULTS

From March 2010 to July 2015, 572 patients completed questionnaires and underwent wrist actigraphy. On admission, patients with COPD had a greater adjusted risk of obstructive sleep apnea (adjusted odds ratio 1.82, 95% confidence interval 1.12-2.96, P = .015) and clinically significant insomnia (adjusted odds ratio 2.07, 95% confidence interval 1.12-3.83, P = .021); no differences were observed for sleep quality or excess sleepiness on admission. After adjustment, compared with patients without COPD, patients with COPD averaged 34 fewer minutes of nightly sleep (95% confidence interval 4.2-64.0 minutes, P = .026), as well as 22.5% lower odds of normal sleep efficiency while in the hospital (95% confidence interval 3.3%-37.9%, P = .024). No statistically significant differences were observed for in-hospital sleep quality, soundness, or ease of falling asleep.

CONCLUSIONS

Among hospitalized patients in medical wards, those with COPD have higher risk of OSA and insomnia and worse in-hospital sleep quality and quantity compared with those without COPD.

Machine learning for nocturnal diagnosis of chronic obstructive pulmonary disease using digital oximetry biomarkers

Objective.Chronic obstructive pulmonary disease (COPD) is a highly prevalent chronic condition. COPD is a major cause of morbidity, mortality and healthcare costs globally. Spirometry is the gold standard test for a definitive diagnosis and severity grading of COPD. However, a large proportion of individuals with COPD are undiagnosed and untreated. Given the high prevalence of COPD and its clinical importance, it is critical to develop new algorithms to identify undiagnosed COPD. This is particularly true in specific disease groups in which the presence of concomitant COPD increases overall morbidity/mortality such as those with sleep-disordered breathing. To our knowledge, no research has looked at the feasibility of automated COPD diagnosis using a data-driven analysis of the nocturnal continuous oximetry time series. We hypothesize that patients with COPD will exert certain patterns and/or dynamics of their overnight oximetry time series that are unique to this condition and that may be captured using a data-driven approach.Approach.We introduce a novel approach to nocturnal COPD diagnosis using 44 oximetry digital biomarkers and five demographic features and assess its performance in a population sample at risk of sleep-disordered breathing. A total ofn=350 unique patients' polysomnography (PSG) recordings were used. A random forest (RF) classifier was trained using these features and evaluated using nested cross-validation.Main results.The RF classifier obtainedF1 = 0.86 ± 0.02 and AUROC = 0.93 ± 0.02 on the test sets. A total of 8 COPD individuals out of 70 were misclassified. No severe cases (GOLD 3-4) were misdiagnosed. Including additional non-oximetry derived PSG biomarkers resulted in minimal performance increase.Significance.We demonstrated for the first time, the feasibility of COPD diagnosis from nocturnal oximetry time series for a population sample at risk of sleep-disordered breathing. We also highlighted what set of digital oximetry biomarkers best reflect how COPD manifests overnight. The results motivate that overnight single channel oximetry can be a valuable modality for COPD diagnosis, in a population sample at risk of sleep-disordered breathing. Further data is needed to validate this approach on other population samples.

Sleep Disturbance, Sleep Disorders and Co-Morbidities in the Care of the Older Person

Sleep complaints can be both common and complex in the older patient. Their consideration is an important aspect of holistic care, and may have an impact on quality of life, mortality, falls and disease risk. Sleep assessment should form part of the comprehensive geriatric assessment. If sleep disturbance is brought to light, consideration of sleep disorders, co-morbidity and medication management should form part of a multifaceted approach. Appreciation of the bi-directional relationship and complex interplay between co-morbidity and sleep in older patients is an important element of patient care. This article provides a brief overview of sleep disturbance and sleep disorders in older patients, in addition to their association with specific co-morbidities including depression, heart failure, respiratory disorders, gastro-oesophageal reflux disease, nocturia, pain, Parkinson's disease, dementia, polypharmacy and falls. A potential systematic multidomain approach to assessment and management is outlined, with an emphasis on non-pharmacological treatment where possible.

Effect of the novel dual orexin receptor antagonist daridorexant on night-time respiratory function and sleep in patients with moderate chronic obstructive pulmonary disease

In patients with chronic obstructive pulmonary disease (COPD), sleep is often fragmented while, conversely, the use of sleep medications is of concern in these patients due to potential impairment of nocturnal breathing. This randomised, double-blind, placebo-controlled, two-period crossover study was conducted to evaluate the effect of the new dual orexin receptor antagonist daridorexant on night-time respiratory function and sleep in patients with moderate COPD. In each period, the highest Phase-III dose of 50 mg daridorexant or placebo was administered once daily in the evening for 5 consecutive days. The primary endpoint was peripheral oxygen saturation (SpO₂ ) during total sleep time (TST) after last dosing. Night-time respiratory function and sleep were further evaluated based on the apnea-hypopnea index (AHI), sleep duration, and objective sleep parameters. Pharmacokinetics, safety, and tolerability were also assessed. Primary endpoint analysis revealed no significant mean treatment difference (i.e. daridorexant - placebo) for SpO₂ during TST as it was 0.18% (90% confidence interval: -0.21 to 0.57). There was also no difference from placebo for SpO₂ during non-rapid eye movement (REM) and REM sleep at Night 5 and after first dosing. The AHI was slightly increased compared to placebo, but not to a clinically meaningful extent. In addition, daridorexant improved objective sleep parameters (i.e. prolonged TST, increased sleep efficiency, and decreased wake after sleep onset), reached expected plasma concentrations, and was safe and well tolerated. In conclusion, single and multiple doses of 50 mg daridorexant do not impair night-time respiratory function and improves sleep in patients with moderate COPD.

Effect of Dietary Nitrate Supplementation on Sleep in Chronic Obstructive Pulmonary Disease Patients

PURPOSE

Poor sleep quality in chronic obstructive pulmonary disease (COPD) is a result of oxygen desaturation secondary to compromised lung function. Nitrate supplementation with dietary beetroot juice is known to elevate plasma nitrate and to increase the efficiency of oxygen utilization in non-COPD individuals; whether it is of therapeutic benefit for sleep quality in COPD has not been reported.

PATIENTS AND METHODS

In a counterbalanced within-subjects design involving 15 COPD patients as subjects, the subjects consumed either beetroot juice containing nitrate (BJ; ∼6.2 mmol NO₃ ^-) or placebo (NO₃ ^- -depleted juice) immediately before a night of polysomnographic monitoring. Nitrate was measured in plasma collected immediately after waking.

RESULTS

While BJ consumption had no effect on the amount of time spent in any sleep stages, wake-to-N2 transitions and direct wake-to-rapid eye movement sleep (REMS) transitions, hallmarks of disordered sleep, were less frequent on the BJ night than on the placebo night. In the last two hours of the BJ night, percent time in REMS increased and delta power during deep (N3) non-REMS decreased, relative to the placebo night. Collectively, the reduced frequency of atypical transitions and the normalization of non-REMS/REMS dynamics after BJ are indicative of an improvement of sleep quality. BJ also resulted in sustained elevation of peripheral oxygen saturation (SpO₂), during episodes of wake after sleep onset. Plasma nitrate was elevated nearly tenfold on the morning after BJ relative to placebo.

CONCLUSION

BJ has a normalizing effect on disordered sleep in COPD, which may be related to improved oxygen delivery.

CLINICAL TRIAL REGISTRATION

The activities of the Regional Committees for Medical and Health Research Ethics (REC) are founded on the Norwegian law on research ethics and medical research. This study was approved by NTNU/REK midt, Det medisinske fakultet, Postboks 8905, 7491 Trondheim (REK midt 2016/1360).

Sleep disordered breathing and chronic obstructive pulmonary disease: a narrative review on classification, pathophysiology and clinical outcomes

Chronic obstructive pulmonary disease (COPD) causes load-capacity-drive imbalance in both wakefulness and sleep, principally driven by expiratory flow limitation and hyperinflation. Sleep imposes additional burdens to the respiratory muscle pump, driven by changes in respiratory muscle tone, neural respiratory drive and consequences of the supine position. COPD patients are therefore at higher risk of decompensation during sleep, which may manifest as altered sleep architecture, isolated nocturnal desaturation, sleep hypoventilation and restless legs. Each form of sleep disordered breathing in COPD is associated with adverse clinical and patient-reported outcomes, including increased risk of exacerbations, hospitalisation, cardiovascular events, reduced survival and poorer quality of life. COPD-obstructive sleep apnoea (OSA) overlap syndrome represents a distinct clinical diagnosis, in which clinical outcomes are significantly worse than in either disease alone, including increased mortality, risk of cardiovascular events, hospitalisation and exacerbation frequency. Sleep disordered breathing is under-recognised by COPD patients and their clinicians, however early diagnosis and management is crucial to reduce the risk of adverse clinical outcomes. In this narrative review, we describe the pathophysiology of COPD and physiological changes that occur during sleep, manifestations and diagnosis of sleep disordered breathing in COPD and associated clinical outcomes.

Evaluation of the Vibe Actigraph in Patients With Chronic Obstructive Pulmonary Disease: A Pilot Study

STUDY OBJECTIVE

To validate the Vibe actigraph in assessing sleep-wake patterns compared to polysomnography (PSG) in patients with COPD.

METHODS

Nine stable COPD patients wore actigraphs while undergoing PSG. The correlation between total sleep time (TST), total sleep period (TSP), sleep onset latency (SOL), wake after sleep onset (WASO), and sleep efficiency was determined for corresponding measurements from the actigraph and PSG. Sensitivity, specificity, and positive and negative predictive values were calculated for the actigraph, considering PSG the gold standard. Levels of agreement between the variables of PSG and the actigraph were estimated using Bland-Altman plots.

RESULTS

A strong and statistically significant correlation was noted between PSG and the actigraph in detecting movement during sleep [mean activity score (counts)], TST and TSP (all r_s = 0.83; p = 0.005). The median agreement of sleep and wake counts between PSG and the actigraph was 73% and the Cohen's Kappa value was 0.66. The medians of sensitivity and specificity of the actigraph for detecting sleep versus PSG were 84 and 66%, respectively. The median positive and negative predictive values of the actigraph were 74 and 72%, respectively.

CONCLUSIONS

This study demonstrated that, under controlled laboratory conditions, the Vibe actigraph in its default settings is a promising tool for the detection of sleep-wake parameters in a small number of ambulatory patients with COPD. Clinical Impact: The actigraph used in this pilot study suggests that these devices could provide clinically relevant information in COPD to better understand the relationship between sleep and health in this population.

Deterioration of Nighttime Respiratory Mechanics in COPD: Impact of Bronchodilator Therapy

BACKGROUND

COPD is associated with nighttime respiratory symptoms, poor sleep quality, and increased risk of nocturnal death. Overnight deterioration of inspiratory capacity (IC) and FEV₁ have been documented previously. However, the precise nature of this deterioration and mechanisms by which evening bronchodilation may mitigate this occurrence have not been studied.

RESEARCH QUESTION

What is the effect of evening dosing of dual, long-acting bronchodilation on detailed nocturnal respiratory mechanics and inspiratory neural drive (IND)?

STUDY DESIGN AND METHODS

A double-blind, randomized, placebo-controlled crossover study assessed the effects of evening long-acting bronchodilation (aclidinium bromide/formoterol fumarate dihydrate: 400/12 μg) or placebo on morning trough IC (12 h after the dose; primary outcome) and serial overnight measurements of spirometry, dynamic respiratory mechanics, and IND (secondary outcomes). Twenty participants with COPD (moderate/severe airway obstruction and lung hyperinflation) underwent serial measurements of IC, spirometry, breathing pattern, esophageal and transdiaphragmatic pressures, and diaphragm electromyography (diaphragmatic electromyography as a percentage of maximum; IND) at 6 time points from 0 to 12 h after the dose and compared with sleeping IND.

RESULTS

Compared with placebo, evening bronchodilation was not associated with increased morning trough IC 12 h after the dose (P = .48); however, nadir IC (lowest IC, independent of time), peak IC, area under the curve for 12 h after the dose, and IC for 10 h after the dose were improved (P < .05). During placebo, total airways resistance, lung hyperinflation, IND, and tidal esophageal and transdiaphragmatic pressure swings all increased significantly overnight compared with baseline evening values; however, each of these parameters improved with bronchodilator treatment (P < .05) with no change in ventilation or breathing pattern.

INTERPRETATION

Respiratory mechanics significantly deteriorated at night during placebo. Although the morning trough IC was unchanged, evening bronchodilator treatment was associated consistently with sustained overnight improvements in dynamic respiratory mechanics and inspiratory neural drive compared with placebo CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT02429765.

Management of the COPD Patient with Comorbidities: An Experts Recommendation Document

Background

Chronic obstructive pulmonary disease (COPD) is associated with multiple comorbidities, which impact negatively on patients and are often underdiagnosed, thus lacking a proper management due to the absence of clear guidelines.

Purpose

To elaborate expert recommendations aimed to help healthcare professionals to provide the right care for treating COPD patients with comorbidities.

Methods

A modified RAND-UCLA appropriateness method consisting of nominal groups to draw up consensus recommendations (6 Spanish experts) and 2-Delphi rounds to validate them (23 Spanish experts) was performed.

Results

A panel of Spanish internal medicine experts reached consensus on 73 recommendations and 81 conclusions on the clinical consequences of the presence of comorbidities. In general, the experts reached consensus on the issues raised with regard to cardiovascular comorbidity and metabolic disorders. Consensus was reached on the use of selective serotonin reuptake inhibitors in cases of depression and the usefulness of referring patients with anxiety to respiratory rehabilitation programmes. The results also showed consensus on the usefulness of investigating the quality of sleep, the treatment of pain with opioids and the evaluation of osteoporosis by lateral chest radiography.

Conclusion

This study provides conclusions and recommendations that are intended to improve the management of the complexity of patients with COPD and important comorbidities, usually excluded from clinical trials.

Multimorbidity in COPD, does sleep matter?

A good night's sleep is a prerequisite for sustainable mental and physical health. Sleep disorders, including sleep disordered breathing, insomnia and sleep related motor dysfunction (e.g., restless legs syndrome), are common in patients with chronic obstructive pulmonary disease (COPD), especially in more severe disease. COPD is commonly associated with multimorbidity, and sleep disorders as a component of this multimorbidity spectrum have a further negative impact on COPD-related comorbidities. Indeed, concomitant diseases in COPD and in obstructive sleep apnea (OSA) are similar, suggesting that the combination of COPD and OSA, the so called OSA-COPD overlap syndrome (OVS), affects patient outcomes. Potential clinically important interactions of OVS exist in cardiovascular and metabolic disease, arthritis, anxiety, depression, neurocognitive disorder and the fatigue syndrome. Correct diagnosis for recognition and treatment of sleep-related disorders in COPD is recommended. However, surprisingly limited information is available and further research and improved diagnostic tools are needed. In the absence of clear evidence, we agree with the recommendation of the Global Initiative on Chronic Obstructive Lung Disease that sleep disorders should be actively searched for and treated in patients with COPD. We believe that both aspects are important components of the holistic approach required in patients with chronic multimorbid conditions.

Subjective sleep quality is associated with disease status in COPD patients. The cross-sectional Greek UNLOCK study

PURPOSE

The association of chronic obstructive pulmonary disease (COPD) severity and related health status with sleep quality remains unclear. We aimed to investigate the association between COPD and sleep quality in the Greek national branch of the UNLOCK cohort.

METHODS

A sample of 257 COPD patients enrolled cross-sectionally from primary care in Greece. Sleep quality was assessed by the COPD and Asthma Sleep Impact Scale (CASIS-7 items) questionnaire (higher score indicates worse sleep quality). We tested for associations of sleep impairment with health status (CAT and mMRC scores), exacerbations, hospitalizations, GOLD 2018 ABCD status, inhaler adherence, frailty, and sense of coherence, adjusting for age, gender, smoking status, and comorbidities.

RESULTS

The majority of patients reported uncontrolled symptoms (91% with ≥ 10 CAT or 61% with ≥ 2 mMRC). Mean (SD) age was 65 (12.3) with 79% males. CASIS-7 mean (SD) score was 37.7 (12.9). After adjustments, CASIS was significantly associated with worse health status (e.g., CASIS increased with CAT ≥ 10 [β = 12.53, (95% CI, 6.82, 18.25); p < 0.001], mMRC ≥ 2 [β = 4.96, (95% CI, 1.56, 8.34); p = 0.004]), COPD severity (CAT-based GOLD BD [β = 8.88 (95% CI, 2.50, 15.26); p = 0.007]), frailty [β = 8.85 (95% CI 4.45,13.25); p < 0.001], and sense of coherence [β = -0.14 (95% CI -0.21, -0.06), p < 001]. When using a CASIS cut-off score of 30 as indicator of sleep impairment, additional to the aforementioned associations, we found increased risk for sleep impairment with ≥ 2 exacerbations/year and poor inhaler adherence (p value < 0.05).

CONCLUSIONS

Our study suggests that worse health status and COPD severity are associated with poor sleep quality in COPD patients.

An update on pulmonary rehabilitation techniques for patients with chronic obstructive pulmonary disease

Introduction: Pulmonary rehabilitation (PR) is one of the core components in the management of patients with chronic obstructive pulmonary disease (COPD). In order to achieve the maximal level of independence, autonomy, and functioning of the patient, targeted therapies and interventions based on the identification of physical, emotional and social traits need to be provided by a dedicated, interdisciplinary PR team.Areas covered: The review discusses cardiopulmonary exercise testing in the selection of different modes of training modalities. Neuromuscular electrical stimulation as well as gait assessment and training are discussed as well as add-on therapies as oxygen, noninvasive ventilator support or endoscopic lung volume reduction in selected patients. The potentials of pulsed inhaled nitric oxide in patients with underlying pulmonary hypertension is explored as well as nutritional support. The impact of sleep quality on outcomes of PR is reviewed.Expert opinion: Individualized, comprehensive intervention based on thorough assessment of physical, emotional, and social traits in COPD patients forms a continuous challenge for health-care professionals and PR organizations in order to dynamically implement and adapt these strategies based on dynamic, more optimal understanding of underlying pathophysiological mechanisms.

Sleep in chronic respiratory disease: COPD and hypoventilation disorders

COPD and obstructive sleep apnoea (OSA) are highly prevalent and different clinical COPD phenotypes that influence the likelihood of comorbid OSA. The increased lung volumes and low body mass index (BMI) associated with the predominant emphysema phenotype protects against OSA whereas the peripheral oedema and higher BMI often associated with the predominant chronic bronchitis phenotype promote OSA. The diagnosis of OSA in COPD patients requires clinical awareness and screening questionnaires which may help identify patients for overnight study. Management of OSA-COPD overlap patients differs from COPD alone and the survival of overlap patients treated with nocturnal positive airway pressure is superior to those untreated. Sleep-related hypoventilation is common in neuromuscular disease and skeletal disorders because of the effects of normal sleep on ventilation and additional challenges imposed by the underlying disorders. Hypoventilation is first seen during rapid eye movement (REM) sleep before progressing to involve non-REM sleep and wakefulness. Clinical presentation is nonspecific and daytime respiratory function measures poorly predict nocturnal hypoventilation. Monitoring of respiration and carbon dioxide levels during sleep should be incorporated in the evaluation of high-risk patient populations and treatment with noninvasive ventilation improves outcomes.

Sleep Disorders and Adherence to Inhalation Therapy in Patients with Chronic Obstructive Pulmonary Disease

Sleep disorders are common in patients with chronic obstructive pulmonary disease (COPD) and are associated with greater disease severity, more frequent exacerbations, greater use of emergency health care, and higher mortality. They may contribute to worsening of COPD course by reducing patients' adherence to treatment. The aim of this study was to evaluate quality of sleep in COPD patients and to assess the relationship between impaired sleep and adherence to inhalation therapy. The study included 106 COPD patients who were asked to answer the Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), and Adherence to Refills and Medications Scale (ARMS). Clinical and demographic data were also collected. We found that over 60% of patients presented with sleep disorders (PSQI ≥5) and 75% with daytime sleepiness. None of the patients presented with optimal adherence to pharmacotherapy. Worse adherence was correlated with greater sleep disorders (r = 0.56; p < 0.001). ARMS questionnaire proved to be of high overall internal consistency (Cronbach's alpha = 0.85). In conclusion, poor quality of sleep coexists with poor adherence to treatment among COPD patients. ARMS was proved to be a reliable tool for the assessment of adherence. Interventions aimed at improving sleep quality may be helpful to improve adherence to inhalation therapy in COPD patients.

Instability of nocturnal parasympathetic nerve function in patients with chronic lung disease with or without nocturnal desaturation

Objective/background

This study was performed to evaluate the association of nocturnal autonomic nerve (AN) dysfunction, especially parasympathetic nerve (PN) function instability, and nocturnal oxygen desaturation (NOD) in patients with chronic lung diseases (CLD).

Patients and methods

Twenty-nine stable CLD patients with irreversible pulmonary dysfunction and mild-to-moderate daytime hypoxemia, 13 CLD patients receiving long-term oxygen therapy (LTOT) with maintained SpO₂ >90%, and 17 senior healthy volunteers underwent two-night examinations of nocturnal AN function by pulse rate variability (PRV) instead of heart rate variation using a photoelectrical plethysmograph simultaneously monitoring SpO₂ and the presence of sleep disordered breathing at home. AN function was examined by instantaneous time–frequency analysis of PRV using a complex demodulation method.

Results

There were no significant differences in mean low frequency/high frequency (HF) ratio (index of sympathetic nerve activity) or mean HF amplitude (index of PN activity) among controls and CLD patients with and without NOD (defined as SpO₂ <90% for at least 3% of total recording time at night). However, the relative times over which the same main HF peak was sustained for at least 20 seconds (%HF_20sec) and 5 minutes in total recording time, indexes of PN function stability, were significantly reduced in CLD patients compared with controls, and further decreased in CLD patients with NOD compared with non-NOD. %HF_20sec was significantly higher in the LTOT group than the NOD group. Furthermore, PaO₂ at rest and nocturnal hypoxia were significantly correlated with PN function instability in CLD patients.

Conclusion

PN function is unstable at night associated with nocturnal hypoxemia in CLD patients, which may reflect poor quality of sleep.

Sleep quality and quality of life in patients with moderate to very severe chronic obstructive pulmonary disease

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is highly associated with obstructive sleep apnea (OSA). Poor sleep quality is found to be related with decreased quality of life (QoL) in patients with COPD but no study assessed this relationship on the basis of nocturnal sleep parameters.

OBJECTIVES

The aim of this study is to explore the relationships between sleep quality, daytime sleepiness and QoL in patients suffering from moderate to very severe COPD with and without sleep apnea assessed objectively and to compare sleep quality, QoL and daytime sleepiness in patients suffering from COPD with and without sleep apnea.

METHODS

Fifty-one patients with stable moderate to very severe COPD (mean age, 59.8 ± 8.1 years) included in the study. The parameters of polygraphic sleep studies (Stardust II, Philips-Respironics) were noted. Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), The Modified Medical Research Council Dyspnea and SF-36 Health Quality Survey were performed.

RESULTS

The rate of OSA was 74.5% (Apnea-Hypopnea Index, >5). out of all the patients, 94% had poor sleep quality (PSQI, >5). Negative correlations were found between PSQI and physical role, social function and mental health of SF-36 subgroups (P < .05). There was no correlation between PSQI, ESS, SF-36, dyspnea and polygraphic parameters (P > .05). In the comparison of patients with or without OSA, the vitality of SF-36 subgroup was found lower in patients with OSA (P < .05).

CONCLUSIONS

In conclusion, irrespective of OSA, patients with COPD are suffering from poor sleep quality and poor sleep quality negatively affects the QoL. Also, COPD and OSA association causes worsened vitality in the terms of health-related QoL.

The effects of depression, anxiety and sleep disturbances on cognitive impairment in patients with chronic obstructive pulmonary disease

The purpose of this study was to investigate the effects of depression, anxiety and sleep disturbances on cognitive functions in chronic obstructive pulmonary disease (COPD) patients. In this prospective case-control study, demographic data, smoking history, depression, anxiety, sleep quality and cognitive status of 48 COPD patients and 36 healthy volunteers aged 40-90 years were recorded. The Beck depression inventory (BDI), the Beck anxiety inventory (BAI), and Pittsburgh Sleep Quality Index (PSQI) were used to assess depression, anxiety and sleep quality, respectively in COPD patients. Cognitive performance was studied by the mini-mental state examination. The mean age of patients with COPD was 65.3 ± 9.4 years, and disease duration was 9.6 ± 7.8 years. Male sex ratio, smoking, BDI score, BAI score, total PSQI score, sleep latency, sleep duration, average use of sleep aids and sleep disturbances in patients with COPD were significantly higher than the control group (p < 0.05). When cognitive impairment was compared by age, FVC, FEV, FEV/FVC, PEF values and smoking, no statistically significant relationship was found (p > 0.05). A statistically significant relationship was established between cognitive impairment and severity of disease, presence of anxiety, presence of depression and sleep quality. In our study, we found that sleep disorders, depression and anxiety comorbid with COPD increased cognitive impairment as well as the severity of disease. We believe that this finding is important in terms of reducing the risk of cognitive impairment, preventing misdiagnosis and treatment of the aforementioned comorbid diseases.

Understanding the impact of symptoms on the burden of COPD

Chronic obstructive pulmonary disease (COPD) imposes a substantial burden on individuals with the disease, which can include a range of symptoms (breathlessness, cough, sputum production, wheeze, chest tightness) of varying severities. We present an overview of the biomedical literature describing reported relationships between COPD symptoms and disease burden in terms of quality of life, health status, daily activities, physical activity, sleep, comorbid anxiety, and depression, as well as risk of exacerbations and disease prognosis. In addition, the substantial variability of COPD symptoms encountered (morning, daytime, and nighttime) is addressed and their implications for disease burden considered. The findings from this narrative review, which mainly focuses on real-world and observational studies, demonstrate the impact of COPD symptoms on the burden of disease and that improved recognition and understanding of their impact is central to alleviating this burden.

Assessment of Sleep Quality and Effects of Relaxation Exercise on Sleep Quality in Patients Hospitalized in Internal Medicine Services in a University Hospital: The Effect of Relaxation Exercises in Patients Hospitalized

This study aims to assess sleep quality and determine the effects of relaxation exercise on sleep quality in patients hospitalized in internal medicine services. In total, 47 patients comprised the control group and did not engage in the exercise intervention--the progressive muscle relaxation exercise, whereas 235 patients were assigned to the intervention group (N = 282). In this study, Description Questionnaire Form and the Pittsburg Sleep Quality Index (PSQI) were used. Most patients (73.8%) had poor sleep quality. The mean pre- and postexercise PSQI scores of the patients in the interventional group were 8.7 ± 4.0 and 6.1 ± 3.3, respectively. The mean pre- and postexercise PSQI scores of the control patients were 6.6 ± 3.5 and 5.6 ± 2.7, respectively. According to this study, the exercises significantly enhanced the quality of sleep. Patients should be encouraged by nurses to perform relaxation exercises.

Effects of aclidinium on determinants of COPD severity: symptoms and quality of life

The pathophysiology of chronic obstructive pulmonary disease (COPD) includes persistent airflow limitation, altered gas exchange, and enhanced chronic inflammatory response. According to disease severity in individual patients, exacerbations and comorbidities frequently occur. The overall nocturnal and daily symptoms have a strong impact on patient quality of life and clinical outcomes. Bronchodilators, by targeting two important aspects of COPD pathophysiology, ie, bronchoconstriction and lung hyperinflation, are the mainstay of therapy for COPD. Aclidinium bromide in particular is an anticholinergic molecule, approved for maintenance bronchodilator treatment of stable COPD, that combines high antimuscarinic activity with strong kinetic selectivity for the M3 receptor subtype. Moreover, the elevated plasma clearance of aclidinium has been related to low systemic bioavailability and low incidence of anticholinergic adverse events, whereas the reduced residence time at M2 receptors provides good cardiovascular safety. Altogether, these characteristics result in a high safety and tolerability profile. This review aims to reappraise the contribution of symptoms and of the level of quality of life determinants on COPD severity and to evaluate how therapeutic strategies with aclidinium may positively impact on these specific determinants of disease severity.

Formoterol fumarate + glycopyrrolate for the treatment of chronic obstructive pulmonary disease

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) is characterized by a high disability and increasing mortality. Bronchodilators are the cornerstone of pharmacological treatment in COPD, while therapeutic optimization with an improvement in symptoms and compliance represent the actual goals. This has led to the development of devices that combine different classes of inhalatory drugs. Recently, a novel combination of the long acting antimuscarinic agent glycopyrronium bromide and the beta2-agonist formoterol fumarate has been developed in a metered dose inhaler delivery system.

AREAS COVERED

The present article will discuss the current unmet needs in pharmacological therapy of COPD, will then briefly cover the pharmacokinetic and pharmacodynamic characteristics of the formoterol/glycopyrronium fixed dose combination and present the novel delivery system based on engineered microparticles and the co-suspension technology. Finally, efficacy and safety results of phase I, II and III trials will be reviewed. Expert commentary: The novel combination therapy of formoterol/glycopyrronium is the first available as a metered dose inhaler and proved to have a good efficacy and safety profile compared to monocomponents and tiotropium. Although still limited, data from phase III trials provide good evidence to consider it a valid option in the pharmacological management of patients with COPD.

Factors responsible for poor sleep quality in patients with chronic obstructive pulmonary disease

Background

Sleep disturbance is a common complaint in patients with chronic obstructive lung disease (COPD). However, the factors resulting in sleep disturbance remain unclear. This retrospective, observational, multicenter study aimed to identify the factors associated with sleep disturbance in patients with COPD.

Methods

The study was a retrospective, observational, and multicenter research. Data including age, sex, body mass index, smoking status, COPD inhaler prescribed, clinical symptoms, pulmonary function tests, medical history of comorbidities, and questionnaires were collected. Parameters including demographics, symptoms, medication, severity, functional classification, and comorbidities were correlated with sleep quality scores.

Results

Among 377 patients with COPD, 200 (53 %) patients experienced poor sleep quality (Pittsburg Sleep Quality Index scores > 5). A significant difference in sleep quality, as measured by PSQI scores, was noted between groups based on the 2011 Global Initiatives for Chronic Obstructive Lung Disease (GOLD) classification system. The most common sleep disturbances included “getting up to use the bathroom” (70.3 %), “wake up at night or early morning” (40.3 %), and “cough and snore loudly at night” (15.9 %). The use of inhaled corticosteroids, the presence of wheezing, COPD Assessment Test (CAT) scores, and Modified Medical Research Council (mMRC) dyspnea scale scores positively correlated with poor sleep quality (odds ratio: 1.51, 1.66, 1.09, and 1.30, respectively). Upon multivariate analysis, the CAT score was an independent factor for poor sleep quality in these patients. With the exception of sleep problem items, based on the CAT questionnaire, phlegm was significantly higher in COPD patients with poor sleep quality.

Conclusions

Poor sleep quality is common among patients with COPD and symptoms including wheeze, phlegm, and inhaled corticosteroid use may contribute to poor sleep quality. The CAT score is a good indicator of poor sleep quality in patients with COPD.

Sex differences in reported and objectively measured sleep in COPD

Background

The aim was to assess and compare reported sleep disturbances and objectively measured sleep in men and women with COPD compared with controls and also explore sex differences.

Methods

A total of 96 patients with COPD and 90 age- and sex-matched controls answered a sleep questionnaire, underwent ambulatory polysomnography, a post-bronchodilatory spirometry, and blood sampling.

Results

Of the patients with COPD, 51% reported sleep disturbances as compared with 31% in controls (P=0.008). Sleep disturbances were significantly more prevalent in males with COPD compared with controls, whereas there was no significant difference in females. The use of hypnotics was more common among patients with COPD compared with controls, both in men (15% vs 0%, P=0.009) and women (36% vs 16%, P=0.03). The men with COPD had significantly longer recorded sleep latency than the male control group (23 vs 9.3 minutes, P<0.001), while no corresponding difference was found in women. In men with COPD, those with reported sleep disturbances had lower forced vital capacity, higher C-reactive protein, myeloperoxidase, and higher prevalence of chronic bronchitis.

Conclusion

The COPD was associated with impaired sleep in men while the association was less clear in women. This was also confirmed by recorded longer sleep latency in male subjects with COPD compared with controls.

[Comorbidities of COPD]

COPD is a slowly progressive chronic respiratory disease causing an irreversible decrease in air flow. The main cause is smoking, which provokes inflammatory phenomena in the respiratory tract. COPD is a serious public health issue, causing high morbidity, mortality and disability. Related comorbidities are linked to ageing, common risk factors and genetic predispositions. A combination of comorbidities increases healthcare costs. For instance, patients with more than two comorbidities represent a quarter of all COPD sufferers but account for half the related health costs. Our review describes different comorbidities and their impact on the COPD prognosis. The comorbidities include: cardiovascular diseases, osteoporosis, denutrition, obesity, ageing, anemia, sleeping disorders, diabetes, metabolic syndrome, anxiety-depression and lung cancer. The prognosis worsens with one or more comorbidities. Clinicians are faced with the challenge of finding practical and appropriate ways of treating these comorbidities, and there is increasing interest in developing a global, multidisciplinary approach to management. Managing this chronic disease should be based on a holistic, patient-centred approach and smoking cessation remains the key factor in the care of COPD patients.

Prevalence and associations of respiratory-related leg movements: the MrOS sleep study

OBJECTIVES

Obstructive respiratory events often terminate with an associated respiratory-related leg movement (RRLM). Such leg movements are not scored as periodic leg movements (periodic limb movements during sleep, PLMS), although the criteria for distinguishing RRLM from PLMS differ between the American Academy of Sleep Medicine (AASM) and the World Association of Sleep Medicine (WASM)/ International Restless Legs Syndrome Study Group (IRLSSG) scoring manuals. Such LMs may be clinically significant in patients with obstructive sleep apnea (OSA). The prevalence and correlation of RRLM in men with OSA were examined.

METHODS

A case-control sample of 575 men was selected from all men with an apnea-hypopnea index (AHI, ≥3% desaturation criteria) ≥ 10 and good data from piezoelectric leg movement sensors at the first in-home sleep study in the MrOS cohort (mean age = 76.8 years). Sleep studies were rescored for RRLMs using five different RRLM definitions varying in both latency of leg movement onset from respiratory event termination and duration of the leg movement. The quartile of RRLM% (the number of RRLM/the number of hypopneas + apneas) was derived.

RESULTS

The nonparametric densities of RRLM% were most influenced by alterations in the latency rather than the duration of the LM. The most liberal RRLM definition (latency 0-5 s, duration 0.5-10 s) led to a median RRLM% of 23.4 (interquartile range 12.41, 37.12) in this sample. The average AHI and arousal index increased as the quartile of RRLM% increased, as well as the prevalence of chronic obstructive pulmonary disease (COPD). The prevalence of those with a history of hypertension decreased as RRLM% increased. The non-Caucasian race was associated with lower RRLM%.

CONCLUSION

Within an elderly sample with moderate to severe OSA, piezoelectric-defined RRLM% is associated with a number of sleep-related and demographic factors. Further study of the optimal definition, predictors, and consequences of RRLM is warranted.

Tiotropium Respimat Soft Mist Inhaler versus HandiHaler to improve sleeping oxygen saturation and sleep quality in COPD

PURPOSE

Patients with chronic obstructive pulmonary disease (COPD) have poor sleep quality as a result of various alterations in oxygenation parameters and sleep macro- and micro-architecture. There is a shortage of data to support the efficacy of long-acting inhaled anticholinergic agents in improving these adverse effects, which are known to have a negative impact on clinical outcomes. We aimed to compare the tiotropium Respimat Soft Mist Inhaler and the HandiHaler in terms of their effects on sleeping oxygen saturation (SaO2) and sleep quality in patients with COPD.

METHODS

In a randomized, open-label, parallel-group trial involving 200 patients with mild to moderate COPD (resting arterial oxygen tension >60 mmHg while awake), we compared the effects of 6 months' treatment with the two devices on sleeping SaO2 and sleep quality. Overnight polysomnography and pulmonary function testing were performed at baseline and after 6 months' treatment.

RESULTS

A total of 188 patients completed the trial. Both groups showed significant improvement in minimum sleep SaO2 and time of sleep spent with SaO2 below 90 (TST90) compared to baseline. The patients using the Respimat had significantly better TST90 than did those using the HandiHaler. Sleep disturbance was highly variable in these patients, but the sleep stage durations were significantly better in the Respimat group.

CONCLUSIONS

Sleeping SaO2 can be improved by tiotropium delivered using either the HandiHaler device or the Respimat Soft Mist Inhaler. However, the patients who used the Respimat device had significantly better TST90 and sleep architecture parameters.

Adverse Respiratory Events Associated With Hypnotics Use in Patients of Chronic Obstructive Pulmonary Disease: A Population-Based Case-Control Study

Insomnia is prevalent in patients with chronic obstructive pulmonary disease (COPD).We conducted a population-based case-control study to evaluate the effects of hypnotics on the risk of adverse respiratory events in patients with COPD.The case-control study was investigated using data retrieved from the Taiwan National Health Insurance Research Database. Patients with newly diagnosed adverse respiratory events (pneumonia, COPD with acute exacerbation, acute respiratory failure, and cardiopulmonary arrest) were included in the case group. Patients with COPD and no history of adverse respiratory events were randomly selected for the control group, which was frequency-matched with the case group according to index date, age (per 10 years), and sex. Patients who had used hypnotics within 1 month meant active users. The odds ratios (ORs) and 95% confidence intervals (CIs) of were calculated using univariable and multivariable logistic regression models.Most of the study participants were male (71.6%), and the mean ages of the participants in the case and control groups were 69.2 (±12.4) and 67.5 (±12.3) years, respectively. After potential confounding factors were adjusting for, the adjusted ORs of adverse respiratory events were 12.0 for active users of benzodiazepines (95% CI, 8.11-17.6) and 10.5 for active users of nonbenzodiazepines (95% CI, 7.68-14.2) compared with the adjusted ORs of those who never used hypnotics.The results of this epidemiological study suggested that hypnotics increased the risk of adverse respiratory events in patients with COPD.

Sleep and Quality of Life in People With COPD

Sleep disorders are very common in patients with chronic obstructive pulmonary disease (COPD). However, it is not clear how sleep disorders and quality of life (QoL) affect each other in the different stages of disease progression. This descriptive-correlational study investigated the relationship between QoL, quality of sleep, and degree of disease progression in 102 outpatients with COPD. The results showed that the QoL in patients with COPD is compromised and worsens with disease progression, and the quality of sleep is significantly associated with QoL and worsened as the disease progressed. The early identification of a risk of alteration of the quality of sleep, especially in nursing care, could facilitate a preventive approach for COPD patients that could positively affect their QoL.