Impaired sleep reduces quality of life in chronic obstructive pulmonary disease

Poor sleep quality, COPD severity and survival according to CASIS and Pittsburgh questionnaires

Poor sleep quality is frequent among COPD patients and it has been related to worse outcomes. The objective of this study was to compare the COPD and Asthma Sleep Impact Scale (CASIS) and the generic Pittsburgh Sleep Quality Index (PSQI) questionnaires as reliable tools for evaluating sleep quality and its relationship with COPD characteristics and survival. Stable COPD patients were prospectively evaluated. Anthropometric, sociodemographic, comorbidity, lung function and treatment data were collected. All patients completed CASIS and PSQI, mMRC dyspnea severity scale, COPD Assessment Test (CAT), sleep apnoea STOP-Bang and Hospital Anxiety and Depression Scale (HADS) questionnaires. Body mass index, airflow Obstruction, Dyspnea and Exacerbations (BODEx) index was calculated. Life status was determined after a mean follow-up of 3.7 (SD 1) years. We included 200 patients, 69.5% male, mean age 65.8 (9) years. Poor sleep was detected in 100 (50%) and 84 patients (42%) according to PSQI and CASIS questionnaires, respectively, with an agreement of 63%. Poor sleep was related to female gender, more severe dyspnea and worse BODEx, HADS and CAT scores according to both questionnaires. PSQI was associated to chronic pain or inferior urinary tract symptoms and CASIS to exacerbations, shorter walked distance in the 6-min walking test and treatment with oral corticosteroids or chronic oxygen. Thirty nine (19.5%) patients died during follow-up. Mortality was not associated to PSQI nor CASIS results. Unlike PSQI, CASIS is more related to COPD severity and its results are not influenced by comorbidities with known impact on sleep quality. In our sample, poor sleep quality was not associated with increased mortality.

The impact of impaired sleep quality on symptom change and future exacerbation of chronic obstructive pulmonary disease

Purpose

Study the impact of impaired sleep quality on symptom change and future exacerbation of chronic obstructive pulmonary disease (COPD) patients.

Methods

This was a prospective study. Patients with COPD were recruited into the study and followed up for one year. Pittsburgh sleep quality index (PSQI) was collected at baseline. Symptom change was assessed with Minimum clinically important difference (MCID) in COPD Assessment Test (CAT) at 6-month visit, which is an indicator to assess symptom improvement. Exacerbation was recorded during the one-year visit. PSQI score > 5 was defined as poor sleep quality, whereas PSQI score ≤ 5 was defined as good sleep quality. MCID was defined as attaining a CAT decrease ≥ 2.

Results

A total of 461 patients were enrolled for final analysis. Two hundred twenty-eight (49.4%) patients had poor sleep quality. Overall, 224 (48.6%) patients attained MCID at 6-month visit and the incidence of exacerbation during the one-year visit was 39.3%. Fewer patients with impaired sleep quality achieved MCID than patients with good sleep quality. Good sleepers were significantly more likely to attain MCID (OR: 3.112, p < 0.001) than poor sleepers. Fewer poor sleepers in GOLD A and D groups attained MCID with ICS/LABA, and fewer poor sleepers in the GOLD D group attained MCID with ICS/LABA/LAMA than good sleepers. Poor sleep quality was a greater risk factor of future exacerbation in Cox regression analysis. The ROC curves showed that PSQI score had a predictive capacity for future exacerbation. More patients with poor sleep quality experienced future exacerbation in GOLD B and D group with treatment of ICS/LABA/LAMA compared to good sleepers.

Conclusions

COPD patients with impaired sleep quality were less likely to achieve symptom improvement and were at increased risk of future exacerbation compared to patients with good sleep quality. Besides, sleep disturbance may affect the symptom improvement and future exacerbation of patients with different inhaled medication or in different GOLD groups.

Changes in Sleep Problems in Patients Who Underwent Surgical Treatment for Degenerative Spinal Disease with a Concurrent Sleep Disorder: A Nationwide Cohort Study in 3183 Patients during a Two-Year Perioperative Period

Sleep disturbance is prevalent in patients with degenerative spinal disease, and recent studies have reported that surgical treatment is more effective for improving sleep quality than conservative treatment. We aimed to investigate the perioperative changes of sleep problems in patients who underwent surgical treatment for degenerative spinal disease with a concurrent sleep disorder, and presented them according to various clinical profiles possibly associated with sleep disturbance. In addition, we identified factors associated with poor sleep improvement after surgery. This study used data from the Korea Health Insurance Review and Assessment Service database from 2016 to 2018. We included 3183 patients aged ≥19 years who underwent surgery for degenerative spinal disease and had a concurrent sleep disorder. Perioperative changes in the two target outcomes, including the use of sleep medication and hospital visits owing to sleep disorders, were precisely investigated according to factors known to be associated with sleep disturbance, including demographics, comorbidities, and spinal regions. Logistic regression analysis was performed to identify factors associated with poor improvement in terms of sleep medication after surgery. All estimates were validated using bootstrap sampling. During the 1-year preoperative period, the use of sleep medications and hospital visits owing to sleep disorder increased continuously. However, they abruptly decreased shortly after surgical treatment, and throughout the 1-year postoperative period, they remained lower than those in the late preoperative period. At the 1-year follow-up, 75.6% (2407 of 3183) of our cohort showed improvement in sleep medication after surgery. Multivariable analysis identified only two variables as significant factors associated with non-improvement in sleep medication after surgery: depressive disorder (odds ratio (OR) = 1.25 [1.06-1.48]; p = 0.008), and migraine (OR = 1.42 [1.04-1.94]; p = 0.028). We could not investigate the actual sleep quality and resultant quality of life; however, our results justify the necessity for further high-quality studies that include such information and would arouse clinicians' attention to the importance of sleep disturbance in patients with degenerative spinal disease.

Poor Sleep Quality Predicts Decline in Physical Health Functioning in Patients with Coronary Heart Disease and Moderating Role of Social Support

Although sleep problems are common among patients with coronary heart disease (CHD), there is a lack of prospective research examining its influence on health consequences over time. This study investigated whether poor sleep quality predicted patients' decline in physical health functioning over 6 months and whether social support buffered its detrimental effect. Participants were 185 patients with CHD, who completed measures of sleep, psychosocial characteristics, and physical health functioning at baseline and 6 months. Hierarchical regression analyses were conducted to examine whether global sleep index and its subscales, including sleep efficiency, perceived sleep quality, and daily disturbances (sleep disturbances and daytime dysfunction), predicted the decline of physical health functioning at 6 months. Social support was examined for its moderating effect in buffering the negative influence of poor sleep quality on physical health functioning over 6 months. Findings showed that poorer global sleep index, especially subscales of daily disturbances and lower sleep efficiency, significantly predicted greater decline of physical health functioning at 6 months, even after adjusting for covariates, including baseline functioning and depression. Moreover, social support was found to buffer the detrimental impact of poor sleep quality, especially low sleep efficiency, on 6-month physical health functioning. Findings suggest that improving sleep quality for patients with CHD may be promising to facilitate their long-term health maintenance.

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.

Association Between Sleep Quality and Pain Intensity in Mild Patients with COPD: A Community Study

Purpose

Poor sleep quality and pain were common and had been proved as an important influenced factor of quality of life for patients with COPD. The association of sleep quality with pain has been observed in other population but remains unclear in mild patients with COPD from a community setting.

Methods

A cross-sectional study was conducted to include eligible mild patients with COPD in Pudong New District of Shanghai. A structured questionnaire was used to collect general and clinical information for the patients. The Chinese version of Pittsburgh Sleep Quality Index (PSQI) and the short form of McGill Pain Questionnaire (SF-MPQ) was used to assess sleep quality and intensity of pain. Logistic regression was performed to test the association between sleeping quality and pain intensity.

Results

Two hundred and sixty-four patients with COPD, with an average age of 64 years (SD 5.78 years), were enrolled, and of 52% were women. Seventy-one (26.9%) participants reported at least one exacerbation during the past year. About 28.2% of the patients were classified as having poor sleep quality. Sleep quality was significantly associated with PRI score (adjusted odds ratio (ORad)=2.16, 95% CI: 1.16–4.00) and PPI rank (ORad=1.90, 95% CI: 1.08–3.34). People with daytime disturbance were more likely to have pain (ORad =2.03, 95% CI: 1.18–3.50).

Conclusion

Poor sleep quality was common in mild patients with COPD in community and was associated with higher pain intensity. Pain may involve an impairment of sleep quality.

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 Duration and Its Associations with Mortality and Quality of Life in Chronic Obstructive Pulmonary Disease: Results from the 2007-2015 KNAHNES

BACKGROUND

While extreme sleep duration negatively affects mortality and health-related quality of life (HRQOL) in general populations, the relationship remains uncertain in patients with chronic obstructive pulmonary disease (COPD).

OBJECTIVES

To evaluate the association between sleep duration and mortality and HRQOL in patients with COPD.

METHODS

We analyzed 3,349 participants with COPD enrolled in the 2007-2015 Korea National Health and Nutrition Examination Survey (KNHANES). Participants aged 40 years or older with a smoking history and prebronchodilator forced expiratory volume in 1 s/forced vital capacity (FEV1/FVC) <0.7 were eligible. The participants were categorized as short sleepers (<6 h), 6-8 h, and long sleepers (>8) according to self-reported sleep duration. The outcome variables were all-cause mortality and HRQOL. HRQOL was measured using the European Quality of Life-5 Dimensions (EQ-5D) index.

RESULTS

During a median of 6.5 years, 386 (11.5%) participants died. In unadjusted Cox regression analysis, short sleepers with COPD had an increased risk of death (hazard ratio, 1.35; 95% confidence interval [CI]: 1.07-1.71). However, this association was not significant after adjusting for sociodemographic factors, BMI, FEV1, and comorbidities. In unadjusted and adjusted multiple linear regression, short sleepers had significantly worse HRQOL. The adjusted means of the EQ-5D index were 0.88 (95% CI: 0.87-0.89) for short sleepers, 0.90 (95% CI: 0.90-0.91) for 6- to 8-h sleepers, and 0.89 (95% CI: 0.87-0.91) for long sleepers (p = 0.01).

CONCLUSIONS

In patients with COPD, sleep duration was not associated with all-cause mortality. However, short sleep duration was significantly associated with worse HRQOL.

Impact of pulmonary rehabilitation in sleep in COPD patients measured by actigraphy

INTRODUCTION

Chronic obstructive pulmonary disease (COPD) patients have poor sleep quality, longer time to sleep onset and frequent nocturnal awakenings. Poor sleep quality in COPD is associated with poor quality of life (QoL), increased exacerbations and increased mortality. Pulmonary rehabilitation (PR) improves functional status and QoL in COPD but effects on sleep are unclear. PR improves subjective sleep quality but there is paucity of objective actigraphy data. We hypothesized that actigraphy would demonstrate subjective and objective improvement in sleep following PR. Paired comparisons (t-test or Wilcoxon-signed-rank test) were performed before and after PR data on all variables.

METHODS

This retrospective study of COPD patients undergoing PR utilized actigraphy watch recordings before and after 8-weeks of PR to assess changes in sleep variables including total time in bed (TBT), total sleep time (TST), sleep onset latency (SOL), sleep efficiency (SE), wakefulness after sleep onset (WASO) and total nocturnal awakenings. A change in Pittsburg Sleep Quality Index (PSQI) was a secondary outcome. PSQI was performed before and after PR.

RESULTS

Sixty-nine patients were included in the final analysis. Most participants were male (97%), non-obese (median BMI 27.5, IQR 24.3 to 32.4 kg/m2) with an average age of 69 ± 8 years and 71% had severe COPD (GOLD stage 3 or 4). Prevalence of poor sleep quality (PSQI ≥5) was 86%. Paired comparisons did not show improvement in actigraphic sleep parameters following 8-weeks PR despite improvements in 6-min-walk distance (6MWD, mean improvement 54 m, 95% CI 34 m to 74 m, p<0.0001) and St. George's Respiratory Questionnaire scores (SGRQ, mean improvement 7.7 points, 95% CI 5.2 to 10.2, p<0.0001). Stratified analysis of all sleep variables by severity of COPD, BMI, mood, mental status, 6-MWD and SGRQ did not show significant improvement after PR. In Veterans with poor sleep quality (PSQI ≥ 5), PR improved subjective sleep quality (PSQI, mean difference 0.79, 95% CI 0.07 to 1.40, p = 0.03).

CONCLUSIONS

Pulmonary rehabilitation improved subjective sleep quality in Veterans who had poor sleep quality at the beginning of the PR but did not improve objective sleep parameters by actigraphy. Our findings highlight the complex interactions among COPD, sleep and exercise.

Contemporary perspectives in COPD: Patient burden, the role of gender and trajectories of multimorbidity

An individual's experience of COPD is determined by many factors in addition to the pathological features of chronic bronchitis and emphysema and the symptoms that derive directly from them. Multimorbidity is the norm rather than the exception, so most people with COPD are living with a range of other medical problems which can decrease overall quality of life. COPD is caused by the inhalation of noxious particles or gases, in particular tobacco smoke, but also by early life disadvantage impairing lung development and by occupations where inhaled exposures are common (e.g. industrial, farming and cleaning work). Wealthy people are therefore relatively protected from developing COPD and people who do develop the condition may have reduced resources to cope. COPD is also no longer a condition that predominantly affects men. The prevalence of COPD among women has equalled that of men since 2008 in many high-income countries, due to increased exposure to tobacco, and in low-income countries due to biomass fuels. COPD is one of the leading causes of death in women in the USA, and death rates attributed to COPD in women in some countries are predicted to overtake those of men in the next decade. Many factors contribute to this phenomenon, but in addition to socioeconomic and occupational factors, there is increasing evidence of a higher susceptibility of females to smoking and pollutants. Quality of life is also more significantly impaired in women. Although most medications (bronchodilators and inhaled corticosteroids) used to treat COPD demonstrate similar trends for exacerbation prevention and lung function improvement in men and women, this is an understudied area and clinical trials frequently have a preponderance of males. A better understanding of gender-based predictors of efficacy of all therapeutic interventions is crucial for comprehensive patient care. There is an urgent need to recognize the increasing burden of COPD in women and to facilitate global improvements in disease prevention and management in this specific population. Many individuals with COPD follow a trajectory of both lung function decline and also multimorbidity. Unfavourable lung function trajectories throughout life have implications for later development of other chronic diseases. An enhanced understanding of the temporal associations underlying the development of coexisting diseases is a crucial first step in unravelling potential common disease pathways. Lessons can be learned from exploring disease trajectories of other NCD as well as multimorbidity development. Further research will be essential to explain how early life risk factors commonly influence trajectories of COPD and other diseases, how different diseases develop in relation to each other in a temporal way and how this ultimately leads to different multimorbidity patterns in COPD. This review integrates new knowledge and ideas pertaining to three broad themes (i) the overall burden of disease in COPD, (ii) an unappreciated high burden in women and (iii) the contrast of COPD trajectories and different multimorbidity patterns with trajectories of other NCD. The underlying pathology of COPD is largely irreversible, but many factors noted in the review are potentially amenable to intervention. Health and social care systems need to ensure that effective treatment is accessible to all people with the condition. Preventive strategies and treatments that alter the course of disease are crucial, particularly for patients with COPD as one of many problems.

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 Triple Therapy with Budesonide-Formoterol-Tiotropium Versus Placebo-Tiotropium on Sleep Quality in Patients with Chronic Obstructive Pulmonary Disease

Background

Factors responsible for poor sleep quality in patients with chronic obstructive pulmonary disease (COPD) includes the effects of medications. This study evaluates the effect of the inhaled triple therapy of budesonide-formoterol-tiotropium versus placebo-tiotropium on sleep quality in COPD patients.

Methods

Twenty-three patients (11 [48%] males; age 55 [51-60, 48--5] years; body mass index [BMI] 25 [22-30, 18-40] kg/m²; forced expiratory volume in 1 second [FEV₁]1.10 [0.80 -1.90, 0.60-2.80] L, 42 [31-62, 24-75] % predicted) were studied. Ten patients were randomized to budesonide-formoterol-tiotropium and 13 patients to placebo-tiotropium. At baseline and after 28 days, patients completed spirometry, polysomnography, an Epworth Sleepiness Scale (ESS), Pittsburgh Sleep Quality Index (PSQI), COPD-specific St George's Respiratory Questionnaire (SGRQ-C) and short form 36 (SF 36).

Results

After 28 days, there was a significant 29% increase in the bedtime FEV₁ in the budesonide-formoterol-tiotropium group (from 0.75 [0.55-1.30, 0.50-2.40] L to 1.00 [0.75-1.55, 0.50-3.00] L, p=0.031), with no change in the placebo-tiotropium group (from 1.20 [0.80-1.50, 0.60-1.90] L to 1.15 [0.75-1.55, 0.50-1.80] L, p=0.91). No significant change was found post treatment in sleep efficiency or total sleep time in both the budesonide-formoterol-tiotropium group (from 78 [72-92, 62-98]% to 88 [77-92, 40-98]%, p=0.70 and 290 [268-358, 252-382] min to 342 [303-358, 157-372] min, p=0.77, respectively) and the placebo-tiotropium group (from 82 [75-88, 46-93]% to 84 [77-87, 62-94]%, p=0.96 and 320 [292-350, 180-378] min to 339 [303-349, 241-366] min, p=0.79, respectively). While there was no significant change in the arousal index in the budesonide-formoterol-tiotropium group (9 [5-16, 0-48] arousals/hour to 14 [9-17, 2-36] arousals/hour, p=0.43), a significant increase was seen in the placebo-tiotropium group (11 [4-13, 3--2] arousals/hour to 17 [11-21, 2-33] arousals/hour, p=0.027). Similarly, there was no change in the ESS in the budesonide-formoterol-tiotropium group (6 [3-8, 0-11] to 6 [5-8, 0-1]), p=0.44), but a marginally significant increase in the placebo-tiotropium group (8 [5-12, 2-18] to 10 [7-13, 5-18], p=0.07), with a significant difference in the ESS 28 days post treatment between the 2 groups (6 [5-8, 0-11] versus 10 [7-13, 5-18], p=0.043). There was no significant change in nocturnal oxygenation, sleep architecture, PSQI, SGRQ-C, or SF 36 in both groups.

Conclusion

In patients with COPD, inhaled triple therapy with budesonide-formoterol-tiotropium as compared to placebo-tiotropium improves pulmonary function while preserving sleep quality and architecture.

Extra-pulmonary manifestations of COPD and the role of pulmonary rehabilitation: a symptom-centered approach

Introduction: Chronic obstructive pulmonary disease (COPD) is a complex and heterogenous disease that is associated with a range of respiratory and non-respiratory symptoms, which highly contribute to the daily burden of the disease. Symptoms burden remains high despite optimal bronchodilator therapy, but pulmonary rehabilitation (PR) is an effective intervention to improve patients' symptoms. A comprehensive interdisciplinary approach within the framework of a PR program is warranted to tackle these complex symptoms and their consequences. Areas covered: This narrative review describes how symptoms of dyspnea, fatigue, cough, sputum, anxiety, depression, pain, sleep disturbances, and cognitive decline arise in COPD and can contribute to several non-pulmonary manifestations of the disease. It also describes evidence of the effectiveness of interdisciplinary PR programs to counteract these symptoms. A literature search was performed on PubMed and Scopus between June and July 2020. Expert opinion: Respiratory and non-respiratory symptoms are highly prevalent, often not comprehensively assessed, and result in several extra-pulmonary manifestations of the disease (physical, emotional and social). Interdisciplinary PR programs can improve these negative manifestations through different pathways, contributing for an effective symptoms' management. A thorough assessment of symptoms (beyond dyspnea) should be routinely performed and may support the identification of treatable traits, allowing the tailoring of PR interventions and assessment of their real-life impact.

The relationship between sleep quality and dyspnoea severity in patients with COPD

Objectives

This study aimed to determine sleep quality, frequency and severity of dyspnoea in COPD patients and to evaluate the relationship between dyspnoea severity and sleep quality.

Method

The sample of the study consisted of 110 patients admitted to the Chest Diseases polyclinic of a private hospital and diagnosed as COPD for at least one year. The data of the study were collected using the “Individual Information Form”, “COPD and Asthma Sleep Scale (CASIS)” and “Medical Research Council (MRC) Dyspnoea Scale”.

Results

It was found that 6.4% of the patients did not experience dyspnoea, 34.5% had mild, 40.9% had moderate, and 18.2% had severe dyspnoea. The mean CASIS score of the patients without dyspnoea was 29.08±7.83, with mild dyspnoea was 40.22±9.30, with moderate dyspnoea was 50.31±8.97 and with severe dyspnoea was 56.96±13.13. There was a statistically significant difference between dyspnoea severity and mean CASIS score (p=0.001). Correlation analysis between MRC dyspnoea scale and CASIS score showed a significant positive correlation (r=0.61 p=0.001).

Conclusion

It was concluded that the majority of COPD patients had moderate or poor sleep quality and dyspnoea. As dyspnoea severity increases, sleep quality decreases.

Dyspnea During Night-Time and at Early Morning in Patients with Stable COPD is Associated with Supine Tidal Expiratory Flow Limitation

Rationale

Patients with chronic obstructive pulmonary disorder (COPD) complain of various COPD-related symptoms with different daily frequencies. During the night-time and at early morning, dyspnea is often reported and may predict an increased risk of COPD exacerbation and hospitalization and all-cause mortality. The aim of the study was to assess the underlying mechanisms of this symptom, seeking functional biomarkers of its occurrence.

Methods

Stable COPD patients with moderate-to-severe airflow obstruction and without confounding comorbidities underwent extensive baseline function respiratory tests. Spirometry, maximal flow-volume curves, lung volumes, and lung diffusion capacity parameters were obtained. Inspiratory capacity was also measured both in seated and supine positions. Forced oscillation technique (FOT) and negative expiratory pressure (NEP) method were used to establish the presence of tidal expiratory flow limitation (EFL) during recumbency. Questionnaires for recording COPD-related symptoms were administered. Sleep-related disturbances reported by the patients were also registered.

Results

Forty-two consecutive COPD patients aged 65±9 completed the protocol. They were divided, according to the absence (NFL) or presence (FL) of supine EFL, in NFL group (n=17) and FL group (n=25). FL COPD patients had more severe airflow obstruction (FEV₁= 46.4±19.4 vs 65.1±12.5% pred., p<0.01) and they showed no increase of supine IC in contrast with NFL COPD patients (ΔIC= 0.080±0.18 vs 0.390±0.28 L, p<0.01). Dyspnea either during night-time and at early morning was significantly more reported in FL COPD patients than in NFL COPD patients (p<0.05) and in those with less than 10% increase in supine IC (p<0.05).

Conclusion

Supine EFL is frequently associated with both night-time and early morning dyspnea, suggesting that the development of recumbent dynamic pulmonary hyperinflation, heralded by the lack of increment of IC in supine position, is a pivotal mechanism of this symptom. No or trivial increase in supine IC may indicate the occurrence of dyspnea under these conditions.

Improvement of sleep quality after treatment in patients with lumbar spinal stenosis: a prospective comparative study between conservative versus surgical treatment

Despite the importance of sleep and the evidence on its relationship with various chronic diseases, quality of sleep is not considered in patients with lumbar spinal stenosis (LSS). This prospective comparative study aimed to investigate the changes in sleep disturbance after treatment in patients with LSS. Patients with LSS and sleep disturbance (n = 201; 147 conservatively treated and 54 patients with surgical treatment) were included. The Pittsburgh sleep quality index (PSQI) was used to evaluate sleep quality. Propensity score matching was used to attenuate the potential bias. Clinical outcome of surgery, as determined by the Oswestry disability index, and the PSQI was compared between the two groups at 6 weeks, 3 months, and 6 months after enrollment. Multivariate logistic analysis was performed to adjust for possible confounders within the matched cohorts. Among the 201 patients, 96 (47.7%) patients were finally matched (48 patients in each group). Sleep quality was initially improved after treatment, regardless of the treatment method. Sleep quality in the surgical group was improved by 6 weeks after surgery and consistently improved during the 6-month follow-up period, despite less use of pain killer. Conversely, the improvement in sleep quality at 6-weeks following conservative treatment was not maintained during the follow-up, although the treatment outcome for LSS measured by ODI was continuously improved. After multivariate logistic regression analysis within propensity score matched cohorts, surgical treatment had a significantly greater chance to improve sleep quality compared to conservative treatment. The failure of sleep improvement in conservative group was significantly associated with depression presented by worse score in Hamilton depression rating scale, and more severe degree of foraminal-type stenosis, which should be carefully considered for conservative treatment of LSS patients with sleep disturbance.

Factors associated with sleep disturbance in patients with chronic obstructive pulmonary disease

INTRODUCTION

Poor sleep quality in patients with chronic obstructive pulmonary disease (COPD) has been associated with poor health outcomes. However, there is a lack of research on factors associated with sleep disturbance in patients with COPD.

OBJECTIVES

We investigated patterns of sleep disturbance and factors associated with sleep impairment in patients with COPD.

METHODS

This was a prospective, multicenter cross-sectional study enrolling a sample of 245 COPD subjects. All patients completed the patient-reported measure, the COPD and Asthma Sleep Impact Scale (CASIS) to assess sleep impairment. The St. George's Respiratory Questionnaire (SGRQ), the 36-item Short-Form health survey (SF-36), Hospital Anxiety and Depression Scale (HADS), and the COPD Self-Efficacy Scale (CSES) were utilized to assess health-related quality of life (HRQL), anxiety/depression and self-efficacy, respectively.

RESULTS

About 35.1% of the patients reported that they had a bad night's sleep. Univariate analysis showed that the CASIS total score was significantly correlated with the modified Medical Research Council dyspnea scale, SGRQ total score, SF-36 PCS, SF-36 MCS, HADS-A, HADS-D and CSES (all P < 0.05). In a multivariate analysis, SGRQ total (r = 0.19, P = 0.006), SF-36 PCS (r = 0.14, P = 0.037), HADS-D (r = 0.24, P ≤ 0.001), and CSES(r = -0.12, P = 0.010) were independently associated with the CASIS score.

CONCLUSIONS

In this study, 35% of clinically stable patients with COPD reported poor sleep quality. Depression, poorer HRQL and self-efficacy were significantly associated with sleep disturbance in patients with COPD.

Prevalence of sleep disturbance in patients with lumbar spinal stenosis and analysis of the risk factors

BACKGROUND CONTEXT

Although sleep quality is indispensable for good quality of life, it has not been properly measured or treated in patients with lumbar spinal stenosis (LSS). Studies that investigate the prevalence of sleep disturbances and identify high-risk patients are essential to help understand mechanisms of sleep disturbance in patients with LSS, develop multimodal treatment strategies, and eventually improve the clinical outcome for LSS.

PURPOSE

The purpose of the study was to investigate the prevalence and status of sleep disturbance in patients with LSS and understand its mechanism by identifying the risk factors.

STUDY DESIGN/SETTING

Cross-sectional study.

PATIENT SAMPLE

Patients diagnosed with LSS.

OUTCOME MEASURES

Pittsburgh sleep quality index (PSQI).

METHODS

A study was performed on patients diagnosed with LSS. Sleep disturbance was evaluated using the PSQI. Clinical and radiologic risk factors of sleep disturbance were investigated by comparing its presence and absence in patients with LSS. Multivariate logistic regression analysis was conducted to identify significant risk factors related to sleep disturbance.

RESULTS

A total of 230 patients with LSS were analyzed in our study, 141 of whom (61.3%) were women, and the average age was 67.7 years. Sleep disturbance (PSQI score≥6) was identified in 66.1% of the patients (152 out of 230). After a multivariate analysis, sleep disturbance was consistently associated with the female sex, a negative score on the depression scale, and a severe foraminal-type stenosis. Oswestry disability index, visual analogue pain scale, and presence of nocturnal pain were not independently associated with sleep disturbance.

CONCLUSIONS

This study identified potential high-risk groups for sleep disturbance among patients with LSS. Proper caution and evaluation for these patients, along with further studies about their treatment outcomes, are required.

Day and Night Control of COPD and Role of Pharmacotherapy: A Review

The topic of 24-hour management of COPD is related to day-to-night symptoms management, specific follow-up and patients' adherence to therapy. COPD symptoms strongly vary during day and night, being worse in the night and early morning. This variability is not always adequately considered in the trials. Night-time symptoms are predictive of higher mortality and more frequent exacerbations; therefore, they should be a target of therapy. During night-time, in COPD patients the supine position is responsible for a different thoracic physiology; moreover, during some sleep phases the vagal stimulation determines increased bronchial secretions, increased blood flow in the bronchial circulation (enhancing inflammation) and increased airway resistance (broncho-motor tone). Moreover, in COPD patients the circadian rhythm may be impaired. The role of pharmacotherapy in this regard is still poorly investigated. Symptoms can be grossly differentiated according to the different phenotypes of the disease: wheezing recalls asthma, while dyspnea is strongly related to emphysema (dynamic hyperinflation) or obstructive bronchiolitis (secretions). Those symptoms may be different targets of therapy. In this regard, GOLD recommendations for the first time introduced the concept of phenotype distinction suggesting the use of inhaled corticosteroids (ICS) particularly when an asthmatic pattern or eosiophilic inflammations are present, and hypothesized different approaches to target symptoms (ie, dyspnea) or exacerbations. Pharmacotherapy should be evaluated and possibly directed on the basis of circadian variations, for instance, supporting the use of twice-daily rapid-action bronchodilators and evening dose of ICS. Recommendations on day and night symptoms monitoring strategies and choice of the specific drug according to patient's profile are still not systematically investigated or established. This review is the summary of an advisory board on the topic "24-hour control of COPD and role of pharmacotherapy", held by five pulmonologists, experts in respiratory pathophysiology, pharmacology and sleep medicine.

The mutual association between dyspnea and depressive symptoms in older adults: a 4-year prospective study

Objectives: dyspnea in daily living (DDL), night-time dyspnea (NTD) and depression are common symptoms in older people. However, how changes in dyspnea may influence and be influenced by modifications in depressive symptoms, so far has not been fully evaluated. We aimed to estimate the extent to which both DDL and NTD could be mutually associated to depressive symptoms in older adults with chronic conditions.Methods: this prospective study includes 2322 community-dwelling individuals aged ≥65 years enrolled in the Progetto Veneto Anziani (Pro.V.A.). At baseline and after 4.4 years, we evaluated the following parameters: DDL, assessed by the Medical Research Council dyspnea scale (MRC); self-reported NTD, assessed by personal interview; depressive symptoms, assessed using the Geriatric Depression Scale (GDS). The strength of the association between dyspnea and depression over the follow-up was evaluated through logistic regression and estimated by odds ratios and 95%Confidence Intervals (95%CI). Corrected risk ratios (RR) were then approximated from odds ratios.Results: GDS changes over the follow-up positively correlated with MRC changes (β = 0.938). Individuals with baseline DDL or NTD and those with incident/worsening DDL showed higher risk of developing or worsening depressive symptoms compared with their counterparts (RR = 3.36 [95%CI 2.11-5.06] for incident depression in people with worsening DDL). Incident or persistent depression increased more than twice the risk of developing DDL and NTD (for incident depression RR = 2.33 [95%CI 1.85-2.83] for DDL, and RR = 2.01 [95%CI 1.27-3.11] for NTD).Conclusions: older people may benefit from a comprehensive evaluation of respiratory and psychological symptoms, which seem to be related to each other in advanced age.

Sleep quality and its association with health-related quality of life of patients on lung transplantation waitlist in Japan

PURPOSE

Poor quality of sleep is a common feature in patients with various lung diseases and affects their health-related quality of life (HRQL). We evaluated sleep quality and HRQL in patients on the waitlist for lung transplantation in Japan.

METHODS

In this prospective study, patient-reported and physiological data were collected from patients newly registered on the waitlist for lung transplantation in Japan. Sleep quality was evaluated using the Pittsburgh Sleep Quality Index (PSQI) and HRQL using the St. George's Respiratory Questionnaire (SGRQ). The frequency of poor sleep quality, correlations between sleep quality and various clinical parameters, and predictive factors of sleep quality were examined.

RESULTS

Of 193 patients, the three most-frequent indications for lung transplantation were interstitial pneumonia (n = 96), pulmonary complications of hematopoietic stem cell transplantation (n = 25), and pulmonary hypertension (n = 17). Poor sleep quality (PSQI > 5) was observed in 102 patients (53%) and was significantly associated with worse Hospital Anxiety and Depression Score (HADS), worse SGRQ score, worse modified Medical Research Council Dyspnea score, and shorter 6-min walk distance. However, it was not associated with sex, pulmonary function, interstitial pneumonia, or arterial blood gas. Stepwise multiple regression analysis indicated that poor sleep quality was explained significantly by HADS anxiety (23%) and SGRQ Symptoms (10%).

CONCLUSION

Poor sleep quality was found to be common among patients on the lung transplantation waitlist in Japan. The two most significant factors responsible for impaired sleep quality were anxiety and respiratory symptoms. Additional care should be taken to ensuring a better quality of sleep for such patients.

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.

The Effects of Daily Sleep Condition on Performances of Physical Fitness among Taiwanese Adults: A Cross-Sectional Study

Physical fitness is a powerful indicator of health. Sleep condition plays an essential role in maintaining quality of life and is an important marker that predicts physical fitness. This study aimed to determine the relationship between sleep conditions (sleep quality, sleep duration, bedtime) and multiple physical fitness indicators (body mass index (BMI), flexibility, abdominal muscle strength and endurance, cardiopulmonary endurance) in a well-characterized population of Taiwanese adults aged 23 to 65. The applied data were obtained from the National Physical Fitness Examination Survey 2014 conducted in Taiwan. We assessed the association of the sleep conditions with physical fitness performances in Taiwanese adults by using the multivariate adaptive regression spline (MARS) method with a total of 69,559 samples. The results show that sleep duration, sleep quality, and bedtime were statistically significant influence factors on physical fitness performances with different degrees. Gender was an important factor that affects the effects of daily sleep conditions on performances of physical fitness. Sleep duration was the most important factor as it was simultaneously correlated with BMI, sit-ups, and sit-and-reach indicators in both genders. Bedtime and sleep quality were only associated with sit-ups performance in both genders.

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.

Evaluation of sleep quality and daytime somnolence in patients with chronic obstructive pulmonary disease in pulmonary rehabilitation

BACKGROUND

Dyspnea, fatigue, and decline in sleep quality are symptoms of chronic obstructive pulmonary disease (COPD). Pulmonary rehabilitation programs have been shown to ameliorate dyspnea and fatigue. However, only a few studies have investigated the effects of pulmonary rehabilitation on the sleep quality of COPD patients. In this study, we analyzed the benefits of a pulmonary rehabilitation program to sleep quality and daytime somnolence in COPD patients.

METHODS

This study was a study of 30 moderate-severe COPD patients. All patients were evaluated by a pulmonologist and underwent polysomnography before participating in the study. For this study, we selected only ex-smokers and patients with sleep apnea were referred to the sleep clinic. These participants were prospectively recruited and not selected based on program completion. Before the start of the program, sleep quality and daytime somnolence of the participants were evaluated using the Pittsburgh Sleep Quality Index (PSQI) and the Epworth Sleepiness Scale (ESS), respectively. Rehabilitation program consisted of muscular training sessions conducted at the gym 3 times per week for 12 weeks. After rehabilitation program, the patients were reassessed and their sleep quality and daytime somnolence were reevaluated using the PSQI and the ESS, respectively.

RESULTS

Before rehabilitation, PSQI evaluation revealed that 73% of the participants had poor sleep quality, and ESS evaluation showed that 86.7% of the participants experienced daytime somnolence. After pulmonary rehabilitation, the PSQI specifically improved in terms of subjective sleep quality and sleep duration (< 0.001), habitual sleep efficiency (0.001), and sleep latency and sleep alterations (0.002) and there was also improvement in the ESS (< 0.001).

CONCLUSION

Pulmonary rehabilitation program of gradually increasing intensity has the potential to provide sleep-related benefits to patients with COPD who have poor sleep quality and daytime somnolence.

TRIAL REGISTRATION

Registro Brasileiro de Ensaios Clínicos (ReBEC) RBR62b4z2.

Sleep Quality and Nocturnal Symptoms in a Community-Based COPD Cohort

Small studies have suggested that patients with chronic obstructive pulmonary disease (COPD) have poor sleep quality. Our aim was to examine the prevalence of subjective sleep-related complaints and predictors of poor sleep quality in a large community-based COPD cohort. We analyzed cross-sectional data on sleep questionnaire responses from the Canadian Cohort of Obstructive Lung Disease (CanCOLD) study, a population-based, prospective longitudinal cohort study across Canada. The cohort comprises a COPD group and two matched non-COPD (never-smokers and ever-smokers) groups. Sleep-related symptoms were assessed using questionnaires including Pittsburgh Sleep Quality Index (PSQI). A total score of PSQI > 5 is indicative of poor sleep quality. Health-related quality of life measures and the presence of mood disturbance were assessed using Short Form-36™ Health Survey (SF-36) multi-item questionnaires and Hospital Anxiety and Depression Scale (HADS), respectively. Predictors of poor sleep quality were analyzed using multivariable logistic regression analysis. Of the 1123 subjects, 263 were healthy controls, 323 at-risk controls, and 537 had COPD (297 had mild, 240 with moderate to severe disease). The mean PSQI score was not significantly different between groups. COPD patients with poor sleep quality had lower diffusion capacity, higher HADS anxiety and depression scores and lower SF-36 mental and physical component summary scores than COPD patients classified as good sleepers. The presence of restless legs and obstructive sleep apnea symptoms, waist circumference, predicted diffusion capacity and HADS anxiety and depression scores were identified as independent predictors of poor sleep quality.

Measurement Structure of the Pittsburgh Sleep Quality Index and Its Association with Health Functioning in Patients with Coronary Heart Disease

Research on the underlying structure of sleep measures in patients with coronary heart disease (CHD) is lacking. Existing research on sleep and health outcomes primarily focused on only one dimension of sleep (e.g., sleep duration), leaving other aspects unexamined. To address this gap, this study examined the measurement structure of Pittsburgh Sleep Quality Index (PSQI) and its associations with health-related quality of life among CHD patients. Participants were 167 CHD patients from a cardiac wellness program. Confirmatory factor analysis revealed that the two-factor structure with sleep efficiency and perceived sleep quality best fitted the data. Concurrent validity analyses with structural equation modeling showed that, when considered simultaneously, perceived sleep quality, but not sleep efficiency, was significantly associated with emotional, physical, and social quality of life. Findings demonstrated that the PSQI consists of two moderately correlated factors that are differentially associated with separate health domains in cardiac patients.

Sleep disturbance in patients with mild-moderate chronic obstructive pulmonary disease

INTRODUCTION

Although sleep problems have an important impact on daily life and health outcome measures in patients with chronic obstructive pulmonary disease (COPD), patterns of sleep disturbance in patients with mild-moderate COPD remain unknown.

OBJECTIVE

The aim of this study was to investigate patterns of sleep disturbance and factors associated with sleep impairment in patients with mild-moderate COPD.

METHODS

This prospective cross-sectional study enrolled 148 male patients with COPD. At enrolment, all patients completed a disease-specific sleep measure, the COPD and Asthma Sleep Impact Scale (CASIS) to assess sleep impairment. Health-related quality of life (HRQL) was measured using the St. George's Respiratory Questionnaire (SGRQ) and the 36-item Short-Form health survey (SF-36). Anxiety and depression status were assessed using the Hospital Anxiety and Depression Scale (HADS). Self-efficacy was measured by the COPD Self-Efficacy Scale (CSES).

RESULTS

The mean age of the subjects was 67 years [standard deviation (SD) = 8.11]. The proportion of patients who indicated that they had a bad night's sleep was 33.1%. Univariated analysis showed that CASIS score was significantly correlated with the modified Medical Research Council (mMRC) dyspnea scale, SGRQ, SF-36 Physical Component Summary, SF-36 Mental Component Summary, HADS-anxiety, HADS-depression and CSES scores (all P < 0.05). In a multivariate analysis, SGRQ and CSES were independently associated with CASIS score.

CONCLUSION

Poorer HRQL and lower self-efficacy are significantly associated with sleep disturbance and perhaps may be improved by better sleep quality. Future research is required to enhance sleep quality in patients with mild-moderate COPD.

Impaired Sleep Quality in COPD Is Associated With Exacerbations: The CanCOLD Cohort Study

BACKGROUND

COPD increases susceptibility to sleep disturbances, which may in turn predispose to increased respiratory symptoms. The objective of this study was to evaluate, in a population-based sample, the relationship between subjective sleep quality and risk of COPD exacerbations.

METHODS

Data were obtained from the Canadian Cohort Obstructive Lung Disease (CanCOLD) study. Participants with COPD who had completed 18 months of follow-up were included. Sleep quality was measured with the Pittsburgh Sleep Quality Index (PSQI) and a three-factor analysis. Symptom-based (dyspnea or sputum change ≥ 48 h) and event-based (symptoms plus medication or unscheduled health services use) exacerbations were assessed. Association of PSQI with exacerbation rate was assessed by using negative binomial regression. Exacerbation-free survival was also assessed.

RESULTS

A total of 480 participants with COPD were studied, including 185 with one or more exacerbations during follow-up and 203 with poor baseline sleep quality (PSQI score > 5). Participants with subsequent symptom-based exacerbations had higher median baseline PSQI scores than those without (6.0 [interquartile range, 3.0-8.0] vs 5.0 [interquartile range, 2.0-7.0]; P = .01), and they were more likely to have baseline PSQI scores > 5 (50.3% vs 37.3%; P = .01). Higher PSQI scores were associated with increased symptom-based exacerbation risk (adjusted rate ratio, 1.09; 95% CI, 1.01-1.18; P = .02) and event-based exacerbation risk (adjusted rate ratio, 1.10; 95% CI, 1.00-1.21; P = .048). The association occurred mainly in those with undiagnosed COPD. Strongest associations were with Factor 3 (sleep disturbances and daytime dysfunction). Time to symptom-based exacerbation was shorter in participants with poor sleep quality (adjusted hazard ratio, 1.49; 95% CI, 1.09-2.03).

CONCLUSIONS

Higher baseline PSQI scores were associated with increased risk of COPD exacerbation over 18 months' prospective follow-up.

Pulmonary Rehabilitation does not Improve Objective Measures of Sleep Quality in People with Chronic Obstructive Pulmonary Disease

Abnormal sleep duration is associated with poor health. Upwards of 50% of people with chronic obstructive pulmonary disease (COPD) report poor sleep quality. The effect of pulmonary rehabilitation on self-reported sleep quality is variable. The aim of this study was to assess the effect of pulmonary rehabilitation on objectively measured sleep quality (via actigraphy) in people with COPD. Sleep quality was assessed objectively using the SenseWear Armband (SWA, BodyMedia, Pittsburgh, PA), worn for ≥4 days before and immediately after completing an 8-week pulmonary rehabilitation program. Sleep characteristics were derived from accelerometer positional data and registration of sleep state by the SWA, determined from energy expenditure. Forty-eight participants (n = 21 male) with COPD (mean (SD), age 70 (10) years, mean FEV₁ 55 (20) % predicted, mean 45 (24) pack year smoking history) contributed pre and post pulmonary rehabilitation sleep data to this analysis. No significant differences were seen in any sleep parameters after pulmonary rehabilitation (p = 0.07-0.70). There were no associations between sleep parameters and measures of quality of life or function (all p > 0.30). Sleep quality, measured objectively using actigraphy, did not improve after an 8-week pulmonary rehabilitation program in individuals with COPD. Whether on-going participation in regular exercise training beyond the duration of pulmonary rehabilitation may influence sleep quality, or whether improving sleep quality could enhance rehabilitation outcomes, is yet to be determined.

The impacts of morning, daytime, and nighttime symptoms on disease burden in real-world patients with COPD

Background

Respiratory symptoms are increasingly recognized as an important consideration in COPD management. Understanding the links between the time(s) of day symptoms are experienced and overall symptom burden could support personalized management strategies. This real-world study aimed to establish the association between the time of day of symptoms and the burden on patients using validated patient-reported outcomes, health care resource utilization, and physician-perceived impact of COPD on patients’ lives.

Materials and methods

Analyses used data from four waves (2012, 2013, 2014, and 2016) of the Respiratory Disease Specific Programme: cross-sectional surveys of patients with COPD in Germany, Italy, Spain, and the UK. Patients were classified by their physicians as having symptoms in the morning (M), daytime (D), and/or nighttime (N) in the 4 weeks before entering the Disease Specific Programme. Outcomes included health care resource utilization, work productivity and activity impairment, COPD Assessment Test, EuroQol 5-dimension 3-level questionnaire with visual analog scale, and Jenkins Sleep Evaluation Questionnaire.

Results

In total, 8,844 patients were included, and 8,185 had evaluable time-of-day symptom data. Physicians reported that in the previous 4 weeks, 25% of patients experienced no symptoms, 16% D only, 17% M/D only, 6% D/N only, 4% M, N, or M/N only, and 32% M/D/N. In general, patients with M/D/N symptoms utilized more health care resources in the previous 12 months, had more prior exacerbations, and reported worse activity impairment, health status, and sleep than other symptom groups, whereas patients with symptoms at any time of the day utilized more resources, experienced more exacerbations, and reported worse health status than patients with no symptoms during the 4 weeks before entering the survey.

Conclusion

Patients experiencing morning, daytime, and nighttime symptoms experience a greater disease burden than those in other groups. An individualized approach to COPD treatment based on the timing and persistence of symptoms may improve outcomes for these patients.

Improving physical activity, sedentary behaviour and sleep in COPD: perspectives of people with COPD and experts via a Delphi approach

Background

Little is known about how to achieve enduring improvements in physical activity (PA), sedentary behaviour (SB) and sleep for people with chronic obstructive pulmonary disease (COPD). This study aimed to: (1) identify what people with COPD from South Australia and the Netherlands, and experts from COPD- and non-COPD-specific backgrounds considered important to improve behaviours; and (2) identify areas of dissonance between these different participant groups.

Methods

A four-round Delphi study was conducted, analysed separately for each group. Free-text responses (Round 1) were collated into items within themes and rated for importance on a 9-point Likert scale (Rounds 2–3). Items meeting a priori criteria from each group were retained for rating by all groups in Round 4. Items and themes achieving a median Likert score of ≥7 and an interquartile range of ≤2 across all groups at Round 4 were judged important. Analysis of variance with Tukey’s post-hoc tested for statistical differences between groups for importance ratings.

Results

Seventy-three participants consented to participate in this study, of which 62 (85%) completed Round 4. In Round 4, 81 items (PA n = 54; SB n = 24; sleep n = 3) and 18 themes (PA n = 9; SB n = 7; sleep n = 2) were considered important across all groups concerning: (1) symptom/disease management, (2) targeting behavioural factors, and (3) less commonly, adapting the social/physical environments. There were few areas of dissonance between groups.

Conclusion

Our Delphi participants considered a multifactorial approach to be important to improve PA, SB and sleep. Recognising and addressing factors considered important to recipients and providers of health care may provide a basis for developing behaviour-specific interventions leading to long-term behaviour change in people with COPD.

Overlap syndrome: Obstructive sleep apnea and chronic obstructive pulmonary disease

Obstructive sleep apnea (OSA) and chronic obstructive pulmonary disease (COPD) both cause an inflammatory response and hypoxia. Patients who have both conditions (overlap syndrome) have increased morbidity and mortality. This article aims to increase awareness of the potential effects that untreated OSA can have on COPD and the importance of treating patients with overlap syndrome.

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.

Neurological and Sleep Disturbances in Bronchiectasis

Bronchiectasis unrelated to cystic fibrosis is a chronic lung disease that is increasingly recognised worldwide. While other common chronic lung conditions such as chronic obstructive lung disease have been associated with cardiovascular disease, there is a paucity of data on the relationship between bronchiectasis and cardiovascular risks such as stroke and sleep disturbance. Furthermore, it is unclear whether other neuropsychological aspects are affected, such as cognition, cerebral infection, anxiety and depression. In this review, we aim to highlight neurological and sleep issues in relation to bronchiectasis and their importance to patient care.

Measurement Properties of Short Lower Extremity Functional Exercise Tests in People With Chronic Obstructive Pulmonary Disease: Systematic Review

BACKGROUND

An increasing variety of short functional exercise tests are reported in people with chronic obstructive pulmonary disease (COPD). Systematic review of the psychometric properties of these exercise tests is indicated.

PURPOSE

The aim of this study was to determine the reliability, validity, and responsiveness of short (duration < 6 min) lower extremity functional exercise tests in people with COPD.

DATA SOURCES

Five databases were searched: MEDLINE, Embase, Scopus, AMED, and CINAHL.

STUDY SELECTION

Studies reporting psychometric properties of short functional exercise tests in people with COPD were included.

DATA EXTRACTION

Two reviewers independently extracted data and rated the quality of each measurement property using the COnsensus-based Standards for the Selection of Health Measurement INstrument (COSMIN).

DATA SYNTHESIS

Twenty-nine studies were identified reporting properties of 11 different tests. Four-meter gait speed [4MGS] and 5 repetition sit-to-stand [5STS] demonstrated high reliability (ICC = .95-.99; .97) with no learning effect (COSMIN study ratings = good--excellent). Their validity for use as a stratification tool anchored against an established prognostic indicator (area under receiver operator characteristics curve [AUC] = 0.72-0.87; 0.82) and responsiveness to change after pulmonary rehabilitation was greatest in more frail people with COPD. Studies of the Timed "Up and Go" [TUG] test support use of a practice test and show discriminative ability to detect falls history and low six-minute walk distance (AUC = 0.77; 0.82, COSMIN ratings = fair-excellent).

LIMITATIONS

Earlier studies were limited by small sample size. Limited data of lower study quality was identified for step tests and the Two-Minute Walk Test.

CONCLUSIONS

Selected short functional exercise tests can complement established exercise capacity measures, in stratification and measuring responsiveness to change especially in people with COPD and lower functional ability.

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.

Physical activity, sedentary behaviour and sleep in COPD guidelines: A systematic review

OBJECTIVES

Physical activity, sedentary and sleep behaviours have strong associations with health. This systematic review aimed to identify how clinical practice guidelines (CPGs) for the management of chronic obstructive pulmonary disease (COPD) report specific recommendations and strategies for these movement behaviours.

METHODS

A systematic search of databases (Medline, Scopus, CiNAHL, EMbase, Clinical Guideline), reference lists and websites identified current versions of CPGs published since 2005. Specific recommendations and strategies concerning physical activity, sedentary behaviour and sleep were extracted verbatim. The proportions of CPGs providing specific recommendations and strategies were reported.

RESULTS

From 2370 citations identified, 35 CPGs were eligible for inclusion. Of these, 21 (60%) provided specific recommendations for physical activity, while none provided specific recommendations for sedentary behaviour or sleep. The most commonly suggested strategies to improve movement behaviours were encouragement from a healthcare provider (physical activity n = 20; sedentary behaviour n = 2) and referral for a diagnostic sleep study (sleep n = 4).

CONCLUSION

Since optimal physical activity, sedentary behaviour and sleep durations and patterns are likely to be associated with mitigating the effects of COPD, as well as with general health and well-being, there is a need for further COPD-specific research, consensus and incorporation of recommendations and strategies into CPGs.

Long-term Recording of Night-Time Respiratory Symptoms in Patients with Stable COPD II-IV

INTRODUCTION

Night-time respiratory symptoms have a considerable impact on sleep and life quality in patients with chronic obstructive pulmonary disease (COPD). Lack of awareness of night-time symptoms can lead to worsened COPD control. Automated long-term monitoring of respiratory symptoms with LEOSound enables assessment of nocturnal wheezing and cough.

METHODS

In this observational study we investigated the prevalence and severity of cough and wheezing in patients with stable COPD [Global Initiative for Chronic Obstructive Lung Disease (GOLD) II-IV] disease for two consecutive nights with the LEOSound system. 48 patients (30 males, 63%) were eligible for inclusion, median age was 67 years, and body mass index (BMI) was 25.3 kg/m².

RESULTS

In 15 out of 48 patients (31%), we found wheezing periods for at least 10-minute duration. Wheezing periods >30 minutes were monitored in seven patients and wheezing periods >60 minutes were monitored in three patients. The maximum duration of wheezing was 470 minutes in one patient with COPD II. The median wheezing rate differed between the COPD stages and between active and non-active smokers. Cough was found in 42 patients (87.5%) with a range of 1-326 events. The cough-period-index in night one was 0.83 n/hour (P25:0.33||P75: 2.04) and night two 0.97 n/hour (P25:0.25||P75: 1.9). Most of the cough events were non-productive with a median of 0.86.

CONCLUSIONS

Night-time symptoms are common in COPD patients. LEOSound offers an opportunity to evaluate objectively night-time symptoms like wheezing and cough in patients with COPD which remain otherwise unnoticed. We found a high incidence of night-time wheezing in these patients, which was related to persistant smoking.

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.

Fatigue and sleepiness determine respiratory quality of life among veterans evaluated for sleep apnea

Background

In those with symptoms indicative of obstructive sleep apnea (OSA), respiratory-specific health-related quality of life (HRQL) may be an important patient-centered outcome. The aim of this study was to assess the associations between sleepiness, fatigue, and impaired general and respiratory-specific HRQL among persons with suspected OSA.

Methods

We evaluated military veterans consecutively referred for suspected OSA with sleep studies yielding apnea-hypopnea index (AHI) values. They also completed the sleepiness (Epworth Sleepiness Scale [ESS]), and fatigue (Fatigue Severity Scale [FSS]) questionnaires, as well as two HRQL instruments (the generic Short-Form SF-12v2 yielding the Physical Component Scale [PCS] and the respiratory-specific Airways Questionnaire [AQ]-20R). Multiple linear regression tested the associations between ESS and FSS (standardized as Z scores for scaling comparability) with AQ-20R, accounting for AHI, SF-12v2-PCS and comorbid respiratory conditions other than OSA.

Results

We studied 1578 veterans (median age 61.1 [IQR 16.8] years; 93.9% males). Of these, 823 (52%) met AHI criteria for moderate to severe OSA (AHI ≥15/h). The majority reported excessive daytime sleepiness (53%; median ESS 11 [IQR 9]) or fatigue (61%; median FSS 42 [IQR 23]). The median AQ-20R was 4 [IQR 1–8]. Controlling for AHI, SF-12v2-PCS, respiratory co-morbid conditions, body mass index, and demographics, both ESS and FSS were significantly associated with poorer AQ-20R: for each; ESS, 1.6 points (95% CI 1.4–1.9), and for FSS, 2.5 points (95% CI, 2.3–2.7).

Conclusions

Greater daytime sleepiness and fatigue are associated with poorer respiratory-specific HRQL, over and above the effects of OSA, respiratory comorbidity, and generic physical HRQL.

A cross-sectional survey of night-time symptoms and impact of sleep disturbance on symptoms and health status in patients with COPD

Background

Sleep disturbance has been termed the forgotten dimension of chronic obstructive pulmonary disease (COPD), but it is clinically important as most patients are affected. This study examined the incremental burden of illness associated with sleep disturbance in COPD, with reference to health status and disease impact, and the degree of concordance between physicians and patients in reporting night-time COPD symptoms.

Methods

Real-world data from >2,500 patients with COPD consulting for routine care were derived from respiratory Disease-Specific Programs conducted in Europe, the USA, and China. Night-time COPD symptom burden was assessed from patient and physician perspectives. Patients completed the Jenkins Sleep Evaluation Questionnaire (JSEQ), COPD assessment test (CAT), and EuroQol five-dimension questionnaire (EQ-5D). A regression approach was used to analyze the relationship between sleep disturbance (JSEQ score) and health status (EQ-5D score), adjusting for confounding variables.

Results

Frequency of night-time symptoms was high and was higher when reported by patients than physicians (69.7% and 65.7%, respectively). According to the JSEQ, 73.3% of patients had trouble falling asleep, 75.3% experienced night-time awakenings, 70.6% had trouble staying asleep, and 67.7% woke after a usual amount of sleep feeling worn out. Over half (52.7%) of patients received maintenance treatment where night-time symptom relief was stated by the physician as a treatment aim. A one unit increase in JSEQ score was associated with increased CAT score (0.7 units in Europe and the USA; 0.2 units in China). Sleep disturbance was significantly associated with worse health status (odds ratio [OR]: 1.27, 95% confidence interval [CI]: 1.18, 1.36, P<0.001 for Europe; OR: 1.23, 95% CI: 1.12, 1.38, P<0.001 for the USA; and OR: 1.19, 95% CI: 1.10, 1.28, P<0.001 for China).

Conclusions

Night-time symptoms and sleep disturbance are common among patients with COPD, and sleep disturbance has a detrimental impact on COPD symptoms and health status.

Analysis of nocturnal actigraphic sleep measures in patients with COPD and their association with daytime physical activity

BACKGROUND

Sleep disturbances are common in patients with chronic obstructive pulmonary disease (COPD) with a considerable negative impact on their quality of life. However, factors associated with measures of sleep in daily life have not been investigated before nor has the association between sleep and the ability to engage in physical activity on a day-to-day basis been studied.

AIMS

To provide insight into the relationship between actigraphic sleep measures and disease severity, exertional dyspnoea, gender and parts of the week; and to investigate the association between sleep measures and next day physical activity.

METHODS

Data were analysed from 932 patients with COPD (66% male, 66.4±8.3 years, FEV₁% predicted=50.8±20.5). Participants had sleep and physical activity continuously monitored using a multisensor activity monitor for a median of 6 days. Linear mixed effects models were applied to investigate the factors associated with sleep impairment and the association between nocturnal sleep and patients' subsequent daytime physical activity.

RESULTS

Actigraphic estimates of sleep impairment were greater in patients with worse airflow limitation and worse exertional dyspnoea. Patients with better sleep measures (ie, non-fragmented sleep, sleeping bouts ≥225 min, sleep efficiency ≥91% and time spent awake after sleep onset <57 min) spent significantly more time in light (p<0.01) and moderate-to-vigorous physical activity (p<0.01).

CONCLUSIONS

There is a relationship between measures of sleep in patients with COPD and the amount of activity they undertake during the waking day. Identifying groups with specific sleep characteristics may be useful information when designing physical activity-enhancing interventions.

Predictors of Increased Daytime Sleepiness in Patients with Chronic Obstructive Pulmonary Disease: A Cross-Sectional Study

Background. Patients with Chronic Obstructive Pulmonary Disease (COPD) suffer from increased daytime sleepiness. The aim of this study was to identify potential predictors of subjective daytime sleepiness with special regard to sleep-related breathing disorder and nocturnal activity. Methods. COPD patients were recruited at the University Hospital Basel, Switzerland. COPD risk groups A-D were determined according to spirometry and COPD Assessment Test (CAT). Breathing disorder evaluation was performed with the ApneaLink device. Nocturnal energy expenditure was measured with the SenseWear Mini Armband. Subjective daytime sleepiness was recorded using the Epworth Sleepiness Scale (ESS). Results. Twenty-two patients (36%) were in COPD risk group A, 28 patients (45%) in risk group B, and 12 patients (19%) in risk groups C + D (n = 62). Eleven patients (18%) had a pathological ESS ≥ 10/24. ESS correlated positively with CAT (r = 0.386, p < 0.01) and inversely with age (r = -0.347, p < 0.01). In multiple linear regression age (β = -0.254, p < 0.05), AHI (β = 0.287, p < 0.05) and CAT score (β = 0.380, p < 0.01) were independent predictors of ESS, while nocturnal energy expenditure showed no significant association (p = 0.619). Conclusion. These findings provide evidence that daytime sleepiness in COPD patients may partly be attributable to nocturnal respiratory disturbances and it seems to mostly affect younger patients with more severe COPD symptoms.

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.

Development of the chronic obstructive pulmonary disease morning symptom diary (COPD-MSD)

BACKGROUND

The morning tends to be the most difficult time of day for many patients with chronic obstructive pulmonary disease (COPD) when symptoms can limit one's ability to perform even simple activities. Morning symptoms have been linked to higher levels of work absenteeism, thereby increasing the already substantial economic burden associated with COPD. A validated patient-reported outcome (PRO) instrument designed to capture morning symptoms will allow for a more comprehensive approach to the evaluation of treatment benefit in COPD clinical trials.

METHODS

A qualitative interview study was conducted among a sample of symptomatic adults with COPD. Concept elicitation interviews (n = 35) were conducted to identify COPD morning symptoms, followed by cognitive interviews (n = 21) to ensure patient comprehension of the items, instructions and response options of the draft COPD Morning Symptom Diary (COPD-MSD). All interview transcript data were coded using ATLAS.ti software for content analysis.

RESULTS

Mean age of the concept elicitation and cognitive interview sample was 65.0 years (±7.5) and 62.3 years (±8.3), respectively. The study sample represented the full range of COPD severity (Global Initiative for Chronic Lung Disease [GOLD] classifications I-IV) and included a mix of racial backgrounds, employment status and educational achievement. During the concept elicitation interviews, the three most frequently reported morning symptoms were shortness of breath (n = 35/35; 100 %), phlegm/mucus (n = 31/35; 88.6 %), and cough (n = 30/35; 85.7 %). A group of clinical and instrument development experts convened to review the concept elicitation data and develop the initial 32-item draft COPD-MSD. Cognitive interviews indicated subjects found the draft COPD-MSD to be comprehensive, clear, and easy to understand. The COPD-MSD underwent minor editorial revisions and streamlining based on cognitive interviews and input from the experts to yield the final 19-item daily diary.

CONCLUSIONS

This study supports the content validity of the new COPD-MSD and positions the diary for quantitative psychometric testing.