Continuous positive airway pressure for obstructive sleep apnoea does not improve asthma control

Understanding how sleep disorders are managed in people with asthma: a scoping review of the literature

OBJECTIVE

People with asthma may experience sleep disturbances due to uncontrolled asthma symptoms and/or co-occurring sleep disorders. Asthma shares pathophysiological pathways with sleep disorders including insomnia and obstructive sleep apnea and the interrelationship between asthma and sleep disorders is bi-directional. Insufficient sleep in general and in people with asthma leads to worsened mental and physical health. How this is managed in people with asthma is less known.

DATA SOURCES

This scoping review examines current literature around sleep health management employed by people with asthma and their care providers. Peer reviewed journal articles on sleep health interventions/management in adults with comorbid asthma were searched for in 4 databases, across 10 years, in a search strategy developed with medical librarians.

STUDY SELECTION

The search led to the inclusion of 13 studies that met the review criteria, which reported sleep management interventions tested in people with sleep disorders comorbid with asthma.

RESULTS

For people with obstructive sleep apnea and asthma, continuous positive pressure devices, oral appliances and bariatric surgery improved sleep and asthma outcomes. Improvements in other sleep disorders and asthma were shown with behavioral interventions and digital interventions including fitness tracker use.

CONCLUSION

The limited studies retrievable on this topic suggest management of sleep disorders in people with asthma is an under-researched area. Future research directed at how and when to assess sleep management in people with asthma will better inform specific guidelines and achieve improved sleep health in this population.

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.

State of the art: Alternative overlap syndrome-asthma and obstructive sleep apnea

In the general population, Bronchial Asthma (BA) and Obstructive Sleep Apnea (OSA) are among the most prevalent chronic respiratory disorders. Significant epidemiologic connections and complex pathogenetic pathways link these disorders via complex interactions at genetic, epigenetic, and environmental levels. The coexistence of BA and OSA in an individual likely represents a distinct syndrome, that is, a collection of clinical manifestations attributable to several mechanisms and pathobiological signatures. To avoid terminological confusion, this association has been named alternative overlap syndrome (vs overlap syndrome represented by the chronic obstructive pulmonary disease-OSA association). This comprehensive review summarizes the complex, often bidirectional links between the constituents of the alternative overlap syndrome. Cross-sectional, population, or clinic-based studies are unlikely to elucidate causality or directionality in these relationships. Even longitudinal epidemiological evaluations in BA cohorts developing over time OSA, or OSA cohorts developing BA during follow-up cannot exclude time factors or causal influence of other known or unknown mediators. As such, a lot of pathophysiological interactions described here have suggestive evidence, biological plausibility, potential or actual directionality. By showcasing existing evidence and current knowledge gaps, the hope is that deliberate, focused, and collaborative efforts in the near-future will be geared toward opportunities to shine light on the unknowns and accelerate discovery in this field of health, clinical care, education, research, and scholarly endeavors.

Exploring the Relationship between Inhaled Corticosteroid Usage, Asthma Severity, and Sleep-Disordered Breathing: A Systematic Literature Review

(1) Background: Sleep-disordered breathing and asthma are often interrelated. Children and adults with asthma are more susceptible to sleep apnea. Inhaled corticosteroids effectively reduce inflammation and prevent structural changes in the airways. Objective: to explore the existing literature to determine whether inhaled corticosteroids play a role in sleep-disordered breathing in patients with asthma. (2) Methods: We conducted a thorough search of the PubMed, Scopus, and Web of Science databases for English-language articles published up to 12 May 2024. We utilized the ROBINS-E tool to assess the risk of bias. (4) Conclusions: 136 articles were discerned upon conducting the literature search. A total of 13 articles underwent exhaustive full-text scrutiny, resulting in 6 being considered non-relevant. The remaining seven articles, assessed for eligibility, were incorporated into the final analysis. Five studies were identified in adults and two in children. In adult patients, inhaled corticosteroids, especially at high doses, appear to increase the risk of sleep apnea in a dose-dependent manner. Moreover, the properties of inhaled corticosteroids, such as particle size, may impact the risk of developing sleep apnea. In children, the severity of asthma is a key factor affecting the prevalence of sleep apnea, whereas inhaled corticosteroids appear to be a less significant risk factor compared to adults. All of the studies reviewed were classified as having a high risk of bias or some concerns regarding bias. Each study revealed at least one type of bias that raised notable concerns. This research highlights a complex interaction between the use of inhaled corticosteroids, the severity of asthma, and the onset of sleep apnea. Additional research is necessary to investigate these relationships further.

Dyspnea and Quality of Life Improvements with Management of Comorbid Obstructive Sleep Apnea in Chronic Lung Disease

Obstructive sleep apnea (OSA) has emerged as a significant and prevalent comorbidity associated with chronic lung diseases, including chronic obstructive pulmonary disease, asthma, and interstitial lung diseases. These overlap syndromes are associated with worse patient-reported outcomes (sleep quality, quality of life measures, mental health) than each condition independently. Observational studies suggest that patients with overlap syndrome who are adherent to positive airway pressure therapy report improved quality of life, sleep quality, depression, and daytime symptoms. Screening for and management of OSA in patients with overlap syndrome should emphasize the interconnected nature of these 2 conditions and the positive impact that OSA management can have on patients' well-being and overall health.

Contribution of Obstructive Sleep Apnea to Asthmatic Airway Inflammation and Impact of Its Treatment on the Course of Asthma

Asthma and obstructive sleep apnea (OSA) are very common respiratory disorders in the general population. Beyond their high prevalence, shared risk factors, and genetic linkages, bidirectional relationships between asthma and OSA exist, each disorder affecting the other's presence and severity. The author reviews here some of the salient links between constituents of the alternative overlap syndrome, that is, OSA comorbid with asthma, with an emphasis on the effects of OSA or its treatment on inflammation in asthma. In the directional relationship from OSA toward asthma, beyond direct influences, multiple factors and comorbidities seem to contribute.

Asthma and obstructive sleep apnea: Unveiling correlations and treatable traits for comprehensive care

Asthma and obstructive sleep apnea (OSA) are common respiratory disorders. They share characteristics such as airway obstruction, poor sleep quality, and low quality of life. They are often present as comorbidities, along with obesity, gastroesophageal reflux disease (GERD), and allergic rhinitis (AR), which impacts the disease's control. In recent years, there has been discussion about the association between these conditions and their pathophysiological and clinical consequences, resulting in worse health outcomes, increased healthcare resource consumption, prolonged hospital stays, and increased morbidity and mortality. Some studies demonstrate that treatment with continuous positive airway pressure (CPAP) can have a beneficial effect on both pathologies. This review summarizes the existing evidence of the association between asthma and OSA at their pathophysiological, epidemiological, clinical, and therapeutic levels. It intends to raise awareness among healthcare professionals about these conditions and the need for further research.

Management of the pediatric patient with asthma and obesity

Asthma and obesity are 2 of the most significant chronic diseases of childhood. Both are major public health problems that have been increasing in prevalence. Obesity increases the risk of developing asthma in children, and in children with asthma, obesity increases asthma severity and morbidity. The nature of this relationship is complex and not fully understood, but some pediatric patients with "obesity-related asthma" may represent a phenotype that differs from the more classical, atopic pediatric asthma. In this review, we investigate and discuss some of the currently available literature regarding treatment for asthma complicated by obesity in the pediatric population. We cover the importance of healthy lifestyle modifications, management of obesity-related comorbidities, and the potential role of nutritional supplementation or modification. We then review recent literature, mostly in adults, investigating the potential role of obesity or diabetes medications in the management of patients with asthma who have obesity. Finally, we discuss some of the necessary next steps before these potential new treatments can be considered as part of the standard clinical management of asthma.

Revisiting Asthma Obstructive Sleep Apnea Overlap: Current Knowledge and Future Needs

Asthma and obstructive sleep apnea are highly prevalent conditions with a high cost burden. In addition to shared risk factors, existing data suggest a bidirectional relationship between asthma and OSA, where each condition can impact the other. Patients with asthma often complain of sleep fragmentation, nocturnal asthma symptoms, daytime sleepiness, and snoring. The prevalence of OSA increases with asthma severity, as evidenced by multiple large studies. Asthma may lower the threshold for arousal in OSA, resulting in the hypopnea with arousal phenotype. Epidemiologic studies in adults have shown that OSA is associated with worse asthma severity, increased frequency of exacerbation, and poor quality of life. The current literature assessing the relationship among OSA, asthma, and CPAP therapy is heavily dependent on observational studies. There is a need for randomized controlled trials to minimize the interference of confounding shared risk factors.

Management of comorbidities in difficult and severe asthma

Difficult-to-treat and severe asthma are challenging clinical entities. In the face of suboptimal asthma control, the temptation for clinicians is to reflexively escalate asthma-directed therapy, including increasing exposure to corticosteroids and commencement of costly but potent biologic therapies. However, asthma control is objectively and subjectively assessed based on measurable parameters (such as exacerbations or variability in pulmonary physiology), symptoms and patient histories. Crucially, these features can be confounded by common untreated comorbidities, affecting clinicians' assessment of asthma treatment efficacy.

Chronic intermittent hypoxia increases airway hyperresponsiveness during house dust mites exposures in rats

INTRODUCTION

Accumulating clinical evidence links Obstructive Sleep Apnea (OSA) with worse outcomes of asthma, but impact on airway function remains sparsely studied. We tested effects of Chronic Intermittent Hypoxia (CIH) - a hallmark of OSA - on airway hyperresponsiveness (AHR), in a rat model of chronic allergen-induced inflammation.

METHODS

Brown Norway rats were exposed to six weeks of CIH or normoxia (NORM) concurrent with weekly house dust mites (HDM) or saline (SAL) challenges. At endpoint, we assessed responses to seven Methacholine (Mch) doses (0, 4, 8, 16, 32, 64, 128 mg/mL) on a FlexiVent system (Scireq). Maximal (or plateau) responses (reactivity) for total respiratory system Resistance (R_rs) and Elastance (E_rs), Newtonian airway resistance (R_N, a measure of central airways function) and tissue damping (G, a measure of distal airways function) were plotted.

RESULTS

HDM/CIH-treated animals demonstrated the highest reactivity to Mch in R_rs and E_rs compared to all other groups (HDM/NORM, SAL/CIH and SAL/NORM p < 0.05 for all comparisons, for doses 5-7 for R_rs, and for doses 4-7 for E_rs). The enhanced R_rs response was due to an increase in G (doses 4-7, p < 0.05 for comparisons to all other groups), whereas R_N was not affected by CIH.

CONCLUSIONS

In rats chronically challenged with HDM, concurrent CIH exposure induces AHR primarily in the distal airways, which affects the respiratory system frequency-dependent elastic properties.

The relationship between obstructive sleep apnea and asthma severity and vice versa: a systematic review and meta-analysis

BACKGROUND

There is a great association between the prevalence of obstructive sleep apnea (OSA) and asthma. Nonetheless, whether OSA impacts lung function, symptoms, and control in asthma and whether asthma increases the respiratory events in OSA are unknown. This meta-analysis aimed to examine the relationship between obstructive sleep apnea and asthma severity and vice versa.

METHODS

We carried out a systematic search of PubMed, EMBASE, and Scopus from inception to September 2022. Primary outcomes were lung function, parameters of polysomnography, the risk of OSA in more severe or difficult-to-control asthmatic patients, and the risk of asthma in patients with more severe OSA. Heterogeneity was examined with the Q test and I² statistics. We also performed subgroup analysis, Meta-regression, and Egger's test for bias analysis.

RESULTS

34 studies with 27,912 subjects were totally included. The results showed that the comorbidity of OSA aggravated lung function in asthmatic patients with a consequent decreased forced expiratory volume in one second %predicted (%FEV1) and the effect was particularly evident in children. %FEV1 tended to decrease in adult asthma patients complicated with OSA, but did not reach statistical significance. Interestingly, the risk of asthma seemed to be slightly lower in patients with more severe OSA (OR = 0.87, 95%CI 0.763-0.998). Asthma had no significant effect on polysomnography, but increased daytime sleepiness assessed by the Epworth Sleepiness Scale in OSA patients (WMD = 0.60, 95%CI 0.16-1.04). More severe asthma or difficult-to-control asthma was independently associated with OSA (odds ratio (OR) = 4.36, 95%CI 2.49-7.64).

CONCLUSION

OSA was associated with more severe or difficult-to-control asthma with decreased %FEV₁ in children. The effect of OSA on lung function in adult patients should be further confirmed. Asthma increased daytime sleepiness in OSA patients. More studies are warranted to investigate the effect of asthma on OSA severity and the impact of different OSA severity on the prevalence of asthma. It is strongly recommended that people with moderate-to-severe or difficult-to-control asthma screen for OSA and get the appropriate treatment.

Association between Previous CPAP and Comorbidities at Diagnosis of Obesity-Hypoventilation Syndrome Associated with Obstructive Sleep Apnea: A Comparative Retrospective Observational Study

Obesity-hypoventilation syndrome (OHS) is associated with many comorbidities. The aim of this study was to evaluate the association between previous continuous positive airway pressure (CPAP) and the prevalence of comorbidities in OHS associated with obstructive sleep apnea (OSA). We performed a retrospective, single-center study at the University Hospital of Martinique, the referral hospital for the island of Martinique. A total of 97 patients with OHS associated with severe OSA on non-invasive ventilation (NIV) were included; 54 patients (56%) had previous treatment of OSA with a positive airway pressure (PAP) device before shifting to NIV (PAP group) and 43 (44%) had no previous treatment of OSA with a PAP device before initiating NIV PAP (no PAP group). Sociodemographic characteristics were similar between groups; there were 40 women (74%) in the PAP group versus 34 (79%) in the no PAP group, mean age at OHS diagnosis was 66 ± 15 versus 67 ± 16 years, respectively, and the mean age at inclusion 72 ± 14 versus 71 ± 15 years, respectively. The average number of comorbidities was 4 ± 1 in the PAP group versus 4 ± 2 in the no PAP group; the mean Charlson index was 5 ± 2 in both groups. The mean BMI was 42 ± 8 kg/m2 in both groups. The mean follow-up duration was 5.8 ± 4.4 years in the PAP group versus 4.7 ± 3.5 years in the no PAP group. Chronic heart failure was less common in patients who had a previous PAP 30% versus 53% (p = 0.02). It is also noted that these patients were diagnosed less often in the context of acute respiratory failure in patients with previous PAP: 56% versus 93% (p < 0.0001). In contrast, asthma patients were more frequent in patients with previous treatment of OSA with a PAP device at the time of OHS diagnosis but not significantly: 37% versus 19% (p = 0.07). Early treatment of severe OSA with a PAP device prior to diagnosis of OHS seems to be associated with a reduced prevalence of cardiac diseases, notably chronic heart failure, in patients diagnosed with OHS associated with severe OSA.

Screening for Obstructive Sleep Apnea in Adults: Updated Evidence Report and Systematic Review for the US Preventive Services Task Force

IMPORTANCE

Obstructive sleep apnea (OSA) is associated with adverse health outcomes.

OBJECTIVE

To review the evidence on screening for OSA in asymptomatic adults or those with unrecognized OSA symptoms to inform the US Preventive Services Task Force.

DATA SOURCES

PubMed/MEDLINE, Cochrane Library, Embase, and trial registries through August 23, 2021; surveillance through September 23, 2022.

STUDY SELECTION

English-language studies of screening test accuracy, randomized clinical trials (RCTs) of screening or treatment of OSA reporting health outcomes or harms, and systematic reviews of treatment reporting changes in blood pressure and apnea-hypopnea index (AHI) scores.

DATA EXTRACTION AND SYNTHESIS

Dual review of abstracts, full-text articles, and study quality. Meta-analysis of intervention trials.

MAIN OUTCOMES AND MEASURES

Test accuracy, excessive daytime sleepiness, sleep-related and general health-related quality of life (QOL), and harms.

RESULTS

Eighty-six studies were included (N = 11 051). No study directly compared screening with no screening. Screening accuracy of the Multivariable Apnea Prediction score followed by unattended home sleep testing for detecting severe OSA syndrome (AHI ≥30 and Epworth Sleepiness Scale [ESS] score &gt;10) measured as the area under the curve in 2 studies (n = 702) was 0.80 (95% CI, 0.78 to 0.82) and 0.83 (95% CI, 0.77 to 0.90). Five studies assessing the accuracy of other screening tools were heterogeneous and results were inconsistent. Compared with inactive control, positive airway pressure was associated with a significant improvement in ESS score from baseline (pooled mean difference, -2.33 [95% CI, -2.75 to -1.90]; 47 trials; n = 7024), sleep-related QOL (standardized mean difference, 0.30 [95% CI, 0.19 to 0.42]; 17 trials; n = 3083), and general health-related QOL measured by the 36-Item Short Form Health Survey (SF-36) mental health component summary score change (pooled mean difference, 2.20 [95% CI, 0.95 to 3.44]; 15 trials; n = 2345) and SF-36 physical health component summary score change (pooled mean difference, 1.53 [95% CI, 0.29 to 2.77]; 13 trials; n = 2031). Use of mandibular advancement devices was also associated with a significantly larger ESS score change compared with controls (pooled mean difference, -1.67 [95% CI, 2.09 to -1.25]; 10 trials; n = 1540). Reporting of other health outcomes was sparse; no included trial found significant benefit associated with treatment on mortality, cardiovascular events, or motor vehicle crashes. In 3 systematic reviews, positive airway pressure was significantly associated with reduced blood pressure; however, the difference was relatively small (2-3 mm Hg).

CONCLUSIONS AND RELEVANCE

The accuracy and clinical utility of OSA screening tools that could be used in primary care settings were uncertain. Positive airway pressure and mandibular advancement devices reduced ESS score. Trials of positive airway pressure found modest improvement in sleep-related and general health-related QOL but have not established whether treatment reduces mortality or improves most other health outcomes.

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.

OSA and Chronic Respiratory Disease: Mechanisms and Epidemiology

Obstructive sleep apnea (OSA) is a highly prevalent disorder that has profound implications on the outcomes of patients with chronic lung disease. The hallmark of OSA is a collapse of the oropharynx resulting in a transient reduction in airflow, large intrathoracic pressure swings, and intermittent hypoxia and hypercapnia. The subsequent cytokine-mediated inflammatory cascade, coupled with tractional lung injury, damages the lungs and may worsen several conditions, including chronic obstructive pulmonary disease, asthma, interstitial lung disease, and pulmonary hypertension. Further complicating this is the sleep fragmentation and deterioration of sleep quality that occurs because of OSA, which can compound the fatigue and physical exhaustion often experienced by patients due to their chronic lung disease. For patients with many pulmonary disorders, the available evidence suggests that the prompt recognition and treatment of sleep-disordered breathing improves their quality of life and may also alter the course of their illness. However, more robust studies are needed to truly understand this relationship and the impacts of confounding comorbidities such as obesity and gastroesophageal reflux disease. Clinicians taking care of patients with chronic pulmonary disease should screen and treat patients for OSA, given the complex bidirectional relationship OSA has with chronic lung disease.

Asthma and Three Colinear Comorbidities: Obesity, OSA, and GERD

Asthma is a complex disease with heterogeneous phenotypes and endotypes that are incompletely understood. Obesity, obstructive sleep apnea, and gastroesophageal reflux disease co-occur in patients with asthma at higher rates than in those without asthma. Although these diseases share risk factors, there are some data suggesting that these comorbidities have shared inflammatory pathways, drive the development of asthma, or worsen asthma control. This review discusses the epidemiology, pathophysiology, management recommendations, and key knowledge gaps of these common comorbidities.

[Obstructive sleep apnea and asthma: Clinical implications]

Obstructive sleep apnea (OSA) and asthma are common respiratory diseases that can coexist in the same patient. Epidemiological and pathophysiological data suggest an independent link between these two diseases. Specially, OSA is frequently associated with non-eosinophilic and with poorly-controlled asthma. Common comorbidities including obesity, gastroesophageal reflux and rhinitis may promote this association. The impact of OSA treatment on the clinical and functional control of asthma has been extensively investigated. Numerous non-randomized studies suggest that continuous positive pressure treatment is likely to improve asthma symptoms, the control of the disease and quality of life in asthmatics with OSA. However, this impact has not been confirmed in the limited randomized trial available. To date, the optimal treatment approach in asthmatics with OSA is the best treatment of each disease separately and the recognition and treatment of comorbidities. When indicated, obesity surgery has a major impact on both diseases.

Complicating effects of obstructive sleep apnea syndrome on the severity of adult asthma

Introduction: Bronchial asthma (BA) and obstructive sleep apnea syndrome (OSAS) are common causes of respiratory disturbance. Many cases of patients with both conditions have been reported, and BA and OSAS may exacerbate each other, but information remains sparse.Methods:We retrospectively evaluated 60 patients under treatment for BA in our department between April 2016 and March 2018 who also underwent portable polysomnography (PSG) for suspected OSAS to assess potential association between PSG results and asthma treatment or respiratory function. BA was diagnosed and treated according to the Asthma Prevention and Management Guideline 2015.Results: We found that BA treatment intensity step was significantly higher for patients with BA who had concurrent moderate or severe OSAS (p = 0.0016). However, neither respiratory function, fraction of exhaled nitric oxide (FeNO), nor forced oscillation technique (FOT) differed significantly between patients with and without OSAS, and apnea hypopnea index was not significantly correlated with respiratory function, FeNO or FOT parameters.Conclusion:We conclude that even though BA patients with OSAS had good respiratory function, their BA was more severe than that of patients without OSAS, suggesting that OSAS may exacerbate BA. Background factors and asthma parameters were not predictive of PSG results, and patients with suspected OSAS should be evaluated proactively by using PSG.

Obstructive sleep apnea and comorbidities: a dangerous liaison

Obstructive sleep apnea (OSA) is a highly prevalent disease, and is traditionally associated with increased cardiovascular risk. The role of comorbidities in OSA patients has emerged recently, and new conditions significantly associated with OSA are increasingly reported. A high comorbidity burden worsens prognosis, but some data suggest that CPAP might be protective especially in patients with comorbidities. Aim of this narrative review is to provide an update on recent studies, with special attention to cardiovascular and cerebrovascular comorbidities, the metabolic syndrome and type 2 diabetes, asthma, COPD and cancer. Better phenotypic characterization of OSA patients, including comorbidities, will help to provide better individualized care. The unsatisfactory adherence to CPAP in patients without daytime sleepiness should prompt clinicians to examine the overall risk profile of each patient in order to identify subjects at high risk for worse prognosis and provide the optimal treatment not only for OSA, but also for comorbidities.