Sleep disorders and health-related quality of life in patients with interstitial lung disease

Untreated Obstructive Sleep Apnea in Interstitial Lung Disease and Impact on Interstitial Lung Disease Outcomes

Subjects with interstitial lung disease (ILD) often suffer from nocturnal cough, insomnia, and poor sleep quality. Subjects with ILD and obstructive sleep apnea (OSA) seem to have relatively mild symptoms from sleep fragmentation compared to subjects with only ILD. The overlap of ILD, OSA, and sleeping hypoxemia may be associated with poor outcome, even though there is no agreement on which sleep parameter is mostly associated with worsening ILD prognosis. Randomized controlled trials are needed to understand when positive airway pressure (PAP) treatment is required in subjects with ILD and OSA and the impact of PAP treatment on ILD progression.

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.

The impact of sleep duration on physical activity in daily life in patients with idiopathic pulmonary fibrosis

BACKGROUND

Despite the high prevalence of sleep disturbances in idiopathic pulmonary fibrosis (IPF), the relationship between physical activity in daily life (PADL) and sleep in this population remains unclear.

OBJECTIVES

Investigate the impact of sleep on different domains of PADL in IPF and characterize their PADL profile.

METHODS

Sixty-seven participants (thirty-three with IPF and thirty-four healthy subjects [control group]) were included. The subjects underwent assessments of pulmonary function, exercise capacity, respiratory and peripheral muscle strength, PADL, sleep, dyspnea, and health-related quality of life. PADL and sleep measures were assessed using an activity monitor (Actigraph®, wGT3x-BT). Associations between sleep and PADL were done using correlation and regression models.

RESULTS

In the IPF, sleep duration at night associated significantly with step counts, sedentary, light, and moderate-to-vigorous physical activity (MVPA) (-0.82 ≤ R ≤ 0.43; p < .05 for all). Lung function and sleep partially explained PADL variables (0.19 ≤ R2 ≤ 0.65, p < .05 for all). Compared to controls, the IPF subjects presented lower step counts, less time spent in MVPA, standing position, and more time spent in lying position (p < .05, for all).

CONCLUSIONS

Sleep duration is associated with PADL in IPF. The PADL profile of patients is worse than in control subjects.

Interstitial Lung Disease Is Associated with Sleep Disorders in Rheumatoid Arthritis Patients

OBJECTIVE

To evaluate sleep disorders and associated factors in patients with rheumatoid-arthritis-associated interstitial lung disease (RA-ILD).

METHODS

We performed an observational study of 35 patients with RA-ILD (cases) and 35 age- and sex-matched RA patients without ILD (controls). We evaluated sleep disorders (Oviedo Sleep Questionnaire), positive psychological factors (resilience using the Wagnild and Young Resilience Scale, emotional intelligence using the 24-item Trait Meta-Mood Scale), anxiety and depression (Hospital Anxiety and Depression Scale), quality of life (36-item short-form survey), and fatigue (Functional Assessment of Chronic Illness Therapy Questionnaire). Other variables studied included the Charlson Comorbidity Index (CCI) and RA activity according to the DAS28-ESR.

RESULTS

Compared to the controls, the cases were characterized by poorer sleep quality with a higher prevalence of insomnia (42% vs. 20%; p = 0.039), greater severity of insomnia (p = 0.001), and lower sleep satisfaction (p = 0.033). They also had poorer resilience and emotional recovery and more severe anxiety and depression. A diagnosis of ILD was the only factor independently associated with the three dimensions of sleep quality. The predictors of poorer sleep satisfaction in patients with RA-ILD were age (β = -0.379), DAS28-ESR (β = -0.331), and usual interstitial pneumonia pattern (β = -0.438). The predictors of insomnia were DAS28-ESR (β = 0.294), resilience (β = -0.352), and CCI (β = 0.377).

CONCLUSIONS

RA-ILD is associated with significant sleep disorders. RA-ILD seems to be an independent risk factor for sleep alterations, with a greater impact on insomnia. Age, disease activity, and comorbidity also play a role in sleep disorders in patients with RA-ILD.

Co-existence of OSA and respiratory diseases and the influence of gender

INTRODUCTION

Sleep-disordered breathing (SDB), especially obstructive sleep apnea (OSA), is commonly associated with respiratory diseases, such as COPD, asthma and interstitial lung disease.

AREAS COVERED

This narrative review aims to comprehensively synthesize the existing information on SDB in respiratory diseases, investigate the role of gender in this association, and highlight the importance of OSA management in improving sleep, quality of life, and disease prognosis in these specific patient populations.

EXPERT OPINION

Research indicates a synergistic link between OSA and chronic respiratory diseases, which leads to greater morbidity and mortality compared to each disorder alone. Given the lack of an optimal OSA screening tool for these patients, a comprehensive patient approach and overnight diagnostic sleep study are imperative. Despite the limited evidence available, it seems that gender has an impact on the prevalence, severity, and susceptibility of this coexistence. Recognizing the role of gender in the coexistence of OSA and other respiratory diseases can enhance everyday medical practice and enable clinicians to adopt a more personalized approach toward optimal screening and diagnosis of these patients.

Role of sleep questionnaires in predicting obstructive sleep apnea amongst interstitial lung diseases patients

Introduction

The co-existence of obstructive sleep apnea (OSA) and interstitial lung diseases (ILD) results in significant morbidity and mortality. So screening for OSA is important for its early diagnosis among ILD patients. The commonly used questionnaires for screening of OSA are Epworth sleep score (ESS) and STOP-BANG. However, the validity of these questionnaires among ILD patients is not well studied. The aim of this study was to assess the utility of these sleep questionnaires in detection of OSA among ILD patients.

Methods

It was a prospective observational study of one year in a tertiary chest centre in India. We enrolled 41 stable cases of ILD who were subjected to self-reported questionnaires (ESS, STOP-BANG, and Berlin questionnaire). The diagnosis of OSA was done by Level 1 polysomnography. The correlation analysis was done between the sleep questionnaires and AHI. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for all the questionnaires. The cutoff values of STOPBANG and ESS questionnaire were calculated from the ROC analyses. P value of <0.05 was considered to be significant.

Results

OSA was diagnosed in 32 (78%) patients with mean AHI of 21.8 ± 17.6.The mean age was 54.8 ± 8.9 years with majority being female (78%) and mean body mass index (BMI) was 29.7 ± 6.4 kg/m2. The mean ESS and STOPBANG score were 9.2 ± 5.4 and 4.3 ± 1.8, respectively, and 41% patients showed high risk for OSA with Berlin questionnaire. The sensitivity for detection of OSA was highest (96.1%) with ESS and lowest with Berlin questionnaire (40.6%). The receiver operating characteristics (ROC) area under curve for ESS was 0.929 with optimum cutoff point of 4, sensitivity of 96.9%, and specificity of 55.6%, while ROC area under curve for STOPBANG was 0.918 with optimum cutoff point of 3, sensitivity of 81.2% and specificity of 88.9%.The combination of two questionnaires showed sensitivity of >90%. The sensitivity also increased with the increasing severity of OSA. AHI showed positive correlation with ESS (r = 0.618, P < 0.001) and STOPBANG (r = 0.770, P < 0.001).

Conclusion

The ESS and STOPBANG showed high sensitivity with positive correlation for prediction of OSA in ILD patients. These questionnaires can be used to prioritize the patients for polysomnography (PSG) among ILD patients with suspicion of OSA.

Prognostic Significance of Obstructive Sleep Apnea in a Population of Subjects with Interstitial Lung Diseases

INTRODUCTION

Obstructive sleep apnea (OSA) is often observed in subjects with interstitial lung disease (ILD). It may have a negative impact on the course of ILD, but its prognostic significance in relation to other known indicators of poor outcome is unclear.

METHODS

After a detailed work-up, including overnight unattended type III polygraphy, all subjects newly diagnosed with ILDs referred to our clinics were followed-up for at least 1.5 years or until death or progression of disease [> 10% decline in forced vital capacity (FVC) below baseline]. We analyzed relationships between some prespecified variables of interest, including sleeping results, to establish parameters predictive of progressive course.

RESULTS

Our population consisted of 46 subjects (mean age 59.6 years; males 61%); 23.9% and 41% had idiopathic pulmonary fibrosis and ILD associated with systemic diseases, respectively. Mean baseline forced vital capacity and diffusion capacity of carbon monoxide were 83% and 57% of predicted, respectively. Mean (± SE) Apnea-Hypopnea Index (AHI) was 17 (± 3) events/h. AHI in the ranges 5-14.9, 15-29.9, and ≥ 30 was recorded in 14 (31%), 6 (13%), and 9 (20%) subjects, respectively. Mean distance covered in the 6-MWG walk test (6MWT) was 302 (± 19) m and 26 subjects (57%) showed exertional oxyhemoglobin desaturation. The median follow-up was about 18 months. Multivariate logistic regression analysis showed that exertional desaturation (HR 8.2; 1.8-36.5 95% CI; p = 0.006) and AHI ≥ 30, namely the threshold of severe OSA (HR 7.5; 1.8-30.6; p = 0.005), were the only independent variables related to progressive disease course.

CONCLUSION

We conclude that exertional desaturation and elevated AHI had independent negative prognostic significance in our ILD population.

Comorbidities of sarcoidosis

Sarcoidosis is a heterogeneous disease, which can affect virtually every body organ, even though lungs and intra thoracic lymph nodes are almost universally affected. The presence of noncaseating granulomas is the histopathological hallmark of the disease, and clinical picture depends on the organs affected. Data about interaction between sarcoidosis and comorbidities, such as cardiovascular and pulmonary diseases, autoimmune disorders, malignancy and drug-related adverse events are limited. Several lung conditions can be associated with sarcoidosis, such as pulmonary hypertension and fibrosis, making it difficult sometimes the differentiation between complications and distinctive pathologies. Their coexistence may complicate the diagnosis of sarcoidosis and contribute to the highly variable and unpredictable natural history, particularly if several diseases are recognised. A thorough assessment of specific disorders that can be associated with sarcoidosis should always be carried out, and future studies will need to evaluate sarcoidosis not only as a single disorder, but also in the light of possible concomitant conditions.Key messagesComorbidities in sarcoidosis are common, especially cardiovascular and pulmonary diseases.In the diagnostic workup, a distinction must be made between sarcoidosis-related complaints and complaints caused by other separate disorders. It can be very difficult to distinguish between complications of sarcoidosis and other concomitant conditions.The coexistence of multiple conditions may complicate the diagnosis of sarcoidosis, affect its natural course and response to treatment.

The prevalence of obstructive sleep apnea in sarcoidosis and its impact on sleepiness, fatigue, and sleep-associated quality of life: a cross-sectional study with matched controls (the OSASA study)

STUDY OBJECTIVES

Patients with sarcoidosis experience fatigue and excessive daytime sleepiness (EDS). However, the underlying pathomechanism is unclear. Studies suggested undiagnosed obstructive sleep apnea (OSA) to be an important contributor, but reliable data on prevalence and impact of OSA in sarcoidosis are scarce.

METHODS

71 adult patients with sarcoidosis, 1-to-1 matched to 71 adult controls according to sex, age, and body mass index were included. Participants underwent structured interviews (including Epworth Sleepiness Scale [ESS], Fatigue Assessment Scale [FAS], and Functional Outcome of Sleep Questionnaire [FOSQ-30]) and level-3 respiratory polygraphy. OSA was defined as apnea-hypopnea index ≥ 5 events/h. Prevalence of OSA was assessed and possible risk factors for OSA in sarcoidosis were investigated.

RESULTS

Mild OSA (AHI ≥ 5 events/h) was prevalent in 32 (45%) sarcoidosis patients vs 22 (31%) controls (P = .040). Sarcoidosis patients presented higher ESS compared with matched controls (P = .037). FAS scores (median [quartile] of 21.5 [16, 27.5]) indicated fatigue in sarcoidosis patients. Patients with EDS (ESS ≥ 11) presented reduced FOSQ-30 results (median [quartile] of 16.7 [15.2, 17.8]). ESS, FAS, and FOSQ were not associated with AHI in sarcoidosis patients. Body mass index, sex, neck circumference, and NoSAS score were predictors for OSA in sarcoidosis.

CONCLUSIONS

The risk for mild OSA is 2.5-fold higher in sarcoidosis patients compared with matched controls. OSA seems not to be the reason for increased sleepiness or fatigue in sarcoidosis. Risk factors such as body mass index, sex, neck circumference, and NoSAS score can be used to screen for OSA in sarcoidosis patients.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: Obstructive Sleep Apnoea in Sarcoidosis (OSASA); URL: https://clinicaltrials.gov/ct2/history/NCT04156789?V_2=View; Identifier: NCT04156789.

CITATION

Roeder M, Sievi NA, Schneider A, et al. The prevalence of obstructive sleep apnea in sarcoidosis and its impact on sleepiness, fatigue, and sleep-associated quality of life: a cross-sectional study with matched controls (the OSASA study). J Clin Sleep Med. 2022;18(10):2415-2422.

Overlaps between obstructive sleep apnoea and other respiratory diseases, including COPD, asthma and interstitial lung disease

In the past, there was limited research relating to the role of sleep in respiratory diseases. Physicians treating these patients tended to focus mainly on the daily disabling symptoms, overlooking the possible significant role of coexisting sleep disorders such as obstructive sleep apnoea (OSA). Nowadays, OSA has been recognised as an important, highly prevalent comorbidity for respiratory diseases such as COPD, asthma and interstitial lung diseases (ILDs). Overlap syndrome refers to the coexistence of chronic respiratory disease and OSA in the same patient. Although, in the past, overlap syndromes have been poorly studied, recent data underline that they result in increased morbidity and mortality compared with either underlying disorder alone. OSA and respiratory disease may be of different severity, and this, along with the existence of various clinical phenotypes, points to the necessity of an individualised therapeutic plan. Early recognition and OSA management could offer key benefits, such as improved sleep, quality of life and disease outcomes.

Educational aims

Describe pathophysiological aspects of OSA in chronic respiratory diseases such as COPD, asthma and ILDs.Understand the bidirectional clinical importance when OSA coexists in chronic respiratory diseases.Review current knowledge of treatment strategies towards an individualised therapeutic plan resulting in patient-centric outcomes.

The Association between Idiopathic Pulmonary Fibrosis and Obstructive Sleep Apnea: A Systematic Review and Meta-Analysis

The prevalence of obstructive sleep apnea (OSA) has greatly increased in recent years. Recent data suggest that severe and moderate forms of OSA affect between 6 and 17% of adults in the general population. Many papers are reporting the significantly increased prevalence of OSA in patients suffering from fibrotic diseases, including idiopathic pulmonary fibrosis (IPF). Therefore, we performed a systematic review and meta-analysis regarding the dependency between IPF and OSA. Due to the lack of papers focusing on IPF among OSA patients, we focused on the prevalence of OSA among IPF patients. In the search strategy, a total of 684 abstracts were identified, 496 after the removal of duplicates. After the screening of titles and abstracts, 31 studies were qualified for further full-text analysis for eligibility criteria. The final analysis was performed on 614 IPF patients from 18 studies, which met inclusion criteria. There were 469 (76.38%) IPF patients with OSA and 145 (23.62%) without. The mean age varied from 60.9 ± 8.1 up to 70.3 ± 7.9. The obtained prevalence was 76.4 (95% CI: 72.9–79.7) and 75.7 (95% CI: 70.1–80.9) for fixed and random effects, respectively. The median prevalence of OSA among non-IPF patients for all the ethnics groups included in this study was 16,4% (IQR: 3.4%–26.8%). The study provides strong evidence for the increased prevalence of OSA in IPF patients when comparing with the general OSA prevalence.

Patients with idiopathic pulmonary fibrosis with and without obstructive sleep apnea: differences in clinical characteristics, clinical outcomes, and the effect of PAP treatment

STUDY OBJECTIVES

Obstructive sleep apnea (OSA) in patients with idiopathic pulmonary fibrosis (IPF) is associated with worse mortality and clinical outcome. We aimed to assess differences between patients with IPF with and without OSA and the effect of positive airway pressure treatment on sleep and overall life quality, morbidity, and mortality in these patients.

METHODS

Forty-five patients with newly diagnosed IPF underwent polysomnography. Using an apnea-hypopnea index ≥ 15 events/h for OSA diagnosis resulted in 16 patients with IPF and 29 with IPF-OSA. The patients completed the Epworth Sleepiness Scale, Pittsburgh Sleep Quality Index, Functional Outcomes in Sleep Questionnaire, Fatigue Severity Scale, Short Form-36 life questionnaire, and Beck Depression Inventory before and at the end of the follow-up period.

RESULTS

Patients with IPF-OSA showed the most severe functional impairments in questionnaires, especially for General Health component of the Short Form-36 life questionnaire (37 vs 58, P = .03). At the 7-year follow-up, 16 (36%) patients had died, 6 (38%) in the IPF group and 10 (35%) in IPF-OSA group. Patients with ≥6-hour positive airway pressure use had better survival compared with patients with <6-hour use (P = .04). Significant improvement was also observed in Epworth Sleepiness Scale (3 vs 6, P = .03), Pittsburgh Sleep Quality Index (5 vs 8, P = .01), and Fatigue Severity Scale (37 vs 48, P = .008) score in patients with ≥4-hour positive airway pressure use.

CONCLUSIONS

OSA plays a significant role on clinical features and quality of life in patients with IPF. Effective positive airway pressure treatment results in a significant improvement in sleepiness, fatigue, sleep quality, and mortality.

CLINICAL TRIAL REGISTRATION

Registry: ClinicalTrials.gov; Name: CPAP Therapy in Patients With Idiopathic Pulmonary Fibrosis and Sleep Apnea; URL: https://clinicaltrials.gov/ct2/show/record/NCT01637831; Identifier: NCT01637831.

The association between sleep quality and quality of life: a population-based study

OBJECTIVES

This study aimed to evaluate the association between sleep quality and quality of life (QoL).

METHODS

This cross-sectional study included 225,541 adults (101,133 men, 124,408 women) who participated in the 2018 Korean Community Health Survey. Multiple sociodemographic and psychosocial variables were evaluated and compared between participants with poor (n = 67,619) and good sleep quality (n = 157,922); sleep quality was subjectively determined using the Pittsburgh Sleep Quality Index (PSQI). The EuroQol five-dimension (EQ-5D) index scores were adjusted for multiple confounding factors and compared between the good and poor sleep quality groups. A logistic regression analysis was used to identify determinants of the lowest quartile of QoL.

RESULTS

The mean EQ-5D index scores were significantly lower in the poor sleep quality group (score 0.85) than in the good sleep quality group (score 0.92; p < 0.001). The multivariate odds ratio (OR) for the lowest quartile of the EQ-5D index scores in the poor sleep quality group versus that in the good sleep quality group was 1.95 (95% confidence interval [CI], 1.89-2.00). Participants with poor sleep quality were more likely than those with good sleep quality to have some or severe problems with physical activity (OR, 1.46; 95% CI, 1.41-1.51), self-control (OR, 1.35; 95% CI, 1.29-1.42), daily activity (OR, 1.44; 95% CI, 1.39-1.50), pain (OR, 1.81; 95% CI, 1.77-1.86), and anxiety/depression (OR, 2.24; 95% CI, 2.17-2.31).

CONCLUSION

Poor sleep quality is associated with impaired QoL, particularly if some or severe problems with anxiety/depression are present.

Relationship between illness perception, fear of progression and quality of life in interstitial lung disease patients: A cross-sectional study

AIMS AND OBJECTIVES

This study aimed to investigate whether fear of progression mediates the association between illness perception and quality of life among interstitial lung disease patients.

BACKGROUND

So far, the physiological treatment of interstitial lung disease is limited. In addition to immunosuppressants such as glucocorticoids, two anti-fibrosis drugs (pirfenidone and nintedanib) have shown moderately beneficial effects on slowing the progression of interstitial lung disease fibrosis. However, none of these drugs has shown reliable or strong beneficial effects on improving quality of life. Psychological care and mental health support strategies focusing on improving patients' quality of life are particularly important.

DESIGN

A cross-sectional study.

METHODS

A convenience sample of patients suffering from interstitial lung disease were enrolled from August to December 2019. Data including sociodemographic and clinical characteristics, illness perception, fear of progression and quality of life were collected. The descriptive analysis and Pearson correlations were analysed by SPSS 26.0 (IBM Corp.). PROCESS v3.4 (by Andrew F. Hayes) macro was applied to analyse the mediating effects. We used the STROBE checklist to report the results.

RESULTS

Both illness perception and fear of progression were correlated with quality of life. Fear of progression mediated the association between illness perception and quality of life. The indirect effect was 0.121, and the proportion of intermediary effect in the main effect was 26.36%.

CONCLUSION

Interstitial lung disease patients experience relatively poor quality of life and fear of progression exerts a mediating role between illness perception and quality of life.

RELEVANCE TO CLINICAL PRACTICE

This study alerts medical staff to pay attention to negative illness perception and excessive fear, which is helpful to formulate effective interventions to manage interstitial lung disease patients' quality of life.

Nocturnal hypoxaemia in interstitial lung disease: a systematic review

BACKGROUND

Patients with interstitial lung disease (ILD) are at risk of developing nocturnal hypoxaemia due to ventilatory restriction and impaired gas exchange that worsen with supine posture and reduced ventilatory drive during sleep. This systematic review synthesised literature on the diagnostic evaluation, epidemiology, associations, management and prognosis of nocturnal hypoxaemia in ILD.

METHODS

Ovid MEDLINE, Embase and CENTRAL databases were searched for eligible studies. Meta-analyses with subgroup analyses were conducted, where possible.

RESULTS

Fifty-three studies were included (total participant number=2590). The most common definition for clinically significant nocturnal hypoxaemia was ≥10% of total sleep time with oxyhaemoglobin saturation <90%, with pooled prevalence of 37%. There were no significant differences in pooled prevalence according to ILD subtype and comorbid obstructive sleep apnoea status. Study heterogeneity precluded meta-analysis of associations and prognosis. Diffusing capacity for carbon monoxide (DLCO) and echocardiographic features for pulmonary hypertension were consistently associated with nocturnal hypoxaemia. There were inconsistent associations between nocturnal hypoxaemia with ILD subtype and severity. Multivariable analyses in most studies demonstrated significant associations of nocturnal hypoxaemia with survival. Two small short-term intervention studies demonstrated that supplemental oxygen of 1-3 L/min corrected nocturnal hypoxaemia, with improved heart rate control during in-laboratory observation and increased serum antioxidant levels after 1 month of therapy.

CONCLUSION

Nocturnal hypoxaemia is common, associated with DLCO impairment and markers suggestive of pulmonary hypertension, and a potential prognostic factor in patients in ILD. There is a need to establish a consensus definition of nocturnal hypoxaemia and evaluate long-term effects of nocturnal supplemental oxygen in ILD.

Obstructive sleep apnea in pulmonary fibrosis

PURPOSE OF REVIEW

In previous years, there was limited research related to the role of sleep in interstitial lung diseases (ILDs). Physicians treating ILD patients tended to focus mainly on the daily disabling symptoms overlooking the possible significant role of coexisting sleep disorders, such as obstructive sleep apnea (OSA). However, recently, there has been a growing interest in OSA in ILDs, as well as OSA effect on sleep, life quality and outcome in these patients with emphasis on idiopathic pulmonary fibrosis (IPF).

RECENT FINDINGS

OSA has been recognized as an important, high-prevalence comorbidity for the diagnosis and management of IPF. This publication provides a summary of the most relevant recent evidence with regard to OSA in various ILDs and especially IPF, including prevalence, clinical presentation, complications, screening and diagnosis. It also provides updated evidence on the role of OSA therapy in improving sleep, quality of life and disease outcome.

SUMMARY

It is too early to characterize OSA and ILDs association as an 'overlap' syndrome. In depth research is needed, including studies with large numbers of ILDs and IPF patients. The main priority is to increase the awareness among physicians for early diagnosis of OSA in ILDs patients.

Prevalence and impact of comorbid obstructive sleep apnoea in diffuse parenchymal lung diseases

Objective

Obstructive sleep apnea (OSA) are increasingly recognized as important features in diffuse parenchymal lung diseases (DPLDs) with differed prevalence and impact reported. The aim of this study is to systematically review the prevalence of comorbid OSA and characterize its impact on clinical and outcome measurements in adults with DPLDs.

Methods

Publications addressing the prevalence of OSA in DPLDs and its impacts on DPLDs were selected from electronic databases. A random-effect model was used to estimate the pooled prevalence of OSA. Odds ratios (ORs) or mean differences (MDs) were used to assess the associations of OSA with clinical and outcome measurements. Heterogeneity was quantified by I² with 95% confidence interval (95% CI).

Results

4 studies comprising 643 participants were included. Overall, the pooled prevalence of OSA among DPLDs was 72% (95% CI: 65–79%; I² = 75.4%). Moderate-severe OSA was observed in 40% patients (95% CI: 28–52%; I² = 90.8%). The prevalence was higher as 76% in idiopathic pulmonary fibrosis (IPF) patients than in connective tissue associated-ILD or sarcoidosis (60%). Although oxygen desaturation during sleep was greater in OSA group compared with non-OSA patients, there was no difference in lung function or systematic comorbidities between the two groups. The associations between OSA and the mortality or disease progression of DPLDs were also systematically reviewed.

Conclusion

In conclusion, OSA is a common comorbidity in DPLD patients, affecting approximately three in four patients, which may exacerbate the nocturnal desaturation and have negative influence on the outcomes. Larger studies with more homogeneous samples are warranted.

Interstitial lung disease and obstructive sleep apnea

Obstructive sleep apnea (OSA) is one of the most common comorbidities in patients with interstitial lung disease (ILD). Growing evidence highlights the significance of sleep disturbance on health outcomes in this population. The relationships between ILD and OSA are complex and possibly bidirectional, with multiple mechanisms postulated for the pathogenic and physiologic links. This review synthesizes current evidence and hypotheses regarding different aspects of the relationships between ILD and OSA, emphasizing the interactions between epidemiology, pathogenesis, and pathophysiology.

Sleep in children and young adults with interstitial and diffuse lung disease

OBJECTIVE

Obstructive sleep apnea (OSA) is common in adult patients with interstitial lung disease (ILD). The aim of the study was to evaluate the prevalence of OSA and sleep quality in children and young adults with children's interstitial and diffuse lung disease (chILD).

METHODS

A polysomnography (PSG) was performed in room air in all consecutive patients followed at a national reference centre between June 2018 and September 2019. Clinical and PSG data were collected.

RESULTS

The PSG data of 20 patients (12 girls, median age 9 (range 0.5-20) years), were analyzed. Seven (35%) patients had pulmonary alveolar proteinosis (PAP), 5 (25%) a disorder of surfactant metabolism, 3 (15%) diffuse pulmonary hemorrhage, 4 (20%) chILD of unknown etiology and one patient had laryngeal and pulmonary sarcoidosis. The median obstructive apnea-hypnea index (OAHI) was normal at 0 events/hour, with a value > 4 events/hour being observed in 2 young adults: an 18-year-old male with PAP and a vital capacity of 27% predicted who had an OAHI of 10.7 events/hour, and a 20-year-old male with laryngeal and pulmonary sarcoidosis who had positional OSA with an OAHI of 19.5 events/hour. The median total sleep time, sleep efficiency, % of wake after sleep onset, and sleep stages were moderately disturbed.

CONCLUSIONS

Moderate or severe OSA was not observed in children <18 years with chILD. Mild or moderate OSA was observed in 2 young adults with PAP and sarcoidosis. As opposed to adults, OSA seems uncommon in children with chILD.

The prevalence of obstructive sleep apnea in interstitial lung disease: a systematic review and meta-analysis

PURPOSE

To evaluate the overall prevalence of obstructive sleep apnea (OSA) in interstitial lung disease (ILD).

METHODS

We performed a systematic search of the academic literature while adhering to the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines on four scientific databases including EMBASE, CENTRAL, Scopus, and MEDLINE. We performed a meta-analysis to evaluate the prevalence and severity of OSA. Severity was defined by apnea-hypopnea index (AHI) as mild (AHI ≥ 5 to < 15/h), moderate (AHI ≥ 15 to < 30/h), and severe (AHI ≥ 30/h).

RESULTS

From 1397 studies, we found 10 eligible studies with 569 patients with ILD (mean age: 65.3 ± 6.0 years). Among these patients, 332 (61%) suffered from OSA with 32% categorized as mild, 17% moderate, and 9% severe.  CONCLUSION: This systematic review and meta-analysis provides preliminary evidence regarding the high prevalence of OSA in ILD.

Health-related quality of life of patients with idiopathic pulmonary fibrosis: a systematic review and meta-analysis

Idiopathic pulmonary fibrosis (IPF) is one of the most common forms of interstitial lung disease presenting in persons 50 years and older. Through a comprehensive review of available studies, we aimed to assess health-related quality of life (HRQoL) of people living with IPF and the instruments used in this assessment.Searches were conducted up to May, 2020. Quality appraisal and data extraction were performed using pre-designed forms. Narrative synthesis approach was used to report results of the systematic review and a random effects model was used for the meta-analysis. A leave-one-out sensitivity analysis was performed, and a trim and fill method was used to assess publication bias.The review included 134 studies. The most used instruments to measure HRQoL were St George's Respiratory Questionnaire (SGRQ), Short Form 36 (SF36) and EuroQoL (EQ5D). Standardised mean scores (95% confidence interval) for these instruments were as follows: SGRQ total score: 44.72 (42.21-47.22); SF36 physical component score (PCS): 37.00 (34.74-39.26) SF36 mental component score (MCS): 50.18 (48.41-51.95); King's Brief Interstitial Lung Disease questionnaire total score: 58.38 (55.26-61.51); and EQ5D utility: 0.73 (0.68-0.79). Analysis of standardised means for both SGRQ and SF36 demonstrated worse scores in physical health domains as compared to mental health domains.This systematic review confirms that IPF negatively affected HRQoL, mostly impacting the physical health domains. This study also demonstrated that a diverse number of instruments are used to evaluate HRQoL. In view of this diversity, a standardised approach to measurement of HRQoL for IPF is important to ensure that comparisons made are reliable.

Obstructive sleep apnea in patients with interstitial lung disease: Prevalence and predictive factors

Interstitial lung diseases (ILDs) are chronic, progressive, parenchymal lung diseases with high morbidity and mortality. In recent studies, the prevalence of obstructive sleep apnea (OSA) in patients with ILD has been reported to be high. However, the prevalence and predictive factors of OSA in Korean ILD patients are not well defined. Therefore, the aim of this study was to evaluate the prevalence and predictive factors of OSA in Korean patients with ILD. Clinical data from 86 patients with ILD enrolled from December 2017 to April 2019 at Haeundae-Paik Hospital, Busan, South Korea, were retrospectively analyzed. OSA was monitored with a level 4 portable device and defined as an apnea-hypopnea index of more than 5 per hour of sleep. The median follow-up period was 7 months. The mean age was 69.8 years, and 64% of participants were men. Among the ILDs, idiopathic pulmonary fibrosis (IPF) was the most common (66.3%), followed by connective tissue disease-associated ILD (16.3%) and cryptogenic organizing pneumonia (5.8%). Forty-six ILD patients (53.5%) were diagnosed with OSA, and IPF patients had OSA more frequently (64.9% vs. 31.0%, p = 0.003) than those with other ILDs. Older age (odds ratio [OR], 1.11, 95% CI 1.04-1.19, p = 0.002), higher body weight (OR 1.05, 95% CI 1.01-1.10, p = 0.012), and diabetes mellitus (OR 4.03, 95% CI 1.26-12.91, p = 0.019) were independent risk factors for OSA in the multivariable logistic regression analysis. In the multivariable Cox analysis, an IPF diagnosis was a significant risk factor for one-year mortality (hazard ratio [HR] 7.92, 95% CI: 1.01-61.83, p = 0.048) in ILD patients; however, OSA was not. In conclusion, half of Korean patients with ILD had OSA. Older age, higher body weight, and diabetes mellitus were risk factors for OSA in patients with ILD.

Frequency of Obstructive Sleep Apnea in Stage I and II Sarcoidosis Subjects Who Had No Corticosteroid Therapy

OBJECTIVES

The number of studies on the frequency of obstructive sleep apnea (OSA) in subjects with sarcoidosis is low. Therefore, we aimed to investigate the frequency and predictors of OSA in subjects with clinically stable stage I and II sarcoidosis who were not taking corticosteroid and/or immunosuppressive drugs. We also evaluated restless legs syndrome (RLS) and periodic leg movements in sleep (PLMS).

MATERIALS AND METHODS

Subjects with clinically stable stage I and II sarcoidosis and not receiving corticosteroid and/or immunosuppressive therapy were included in the study. Upper airway examination, lung function tests (forced vital capacity [FVC], forced expiratory volume in 1 second [FEV1], diffusing capacity of the lungs for carbon monoxide [DLCO]), and polysomnography were performed on all subjects. In addition, subjects' Epworth Sleepiness Scale (ESS) scores and the Pittsburgh Sleep Quality Index (PSQI) were recorded.

RESULTS

Of the total number of 46 sarcoidosis subjects (35 women, 11 men; age: 44.4±10.7 years; body mass index (BMI): 29.3±5 kg/m2), 28 (60.9%) were detected with OSA (67.8% mild OSA). The recorded ESS score of the subjects was low (2.6±3.2), whereas the sleep quality was poor in 36.9% of these subjects. Rapid eye movements (REM) related OSA was diagnosed in 14.2% of the OSA subjects. Age was the only factor related to OSA diagnosis in a logistic regression analysis (p=0.048). None of the subjects were diagnosed with RLS and PLMS.

CONCLUSION

OSA is common in stage I and II sarcoidosis subjects who did not receive corticosteroid therapy. The frequency of OSA diagnosis increases as the age of the subjects increases. Therefore, sarcoidosis subjects should be evaluated for OSA throughout the follow-up.

Extended Exhaled Nitric Oxide Analysis in Interstitial Lung Diseases: A Systematic Review

Fractional exhaled nitric oxide (FeNO) is a well-known and widely accepted biomarker of airways inflammation that can be useful in the therapeutic management, and adherence to inhalation therapy control, in asthmatic patients. However, the multiple-flows assessment of FeNO can provide a reliable measurement of bronchial and alveolar production of NO, supporting its potential value as biomarker also in peripheral lung diseases, such as interstitial lung diseases (ILD). In this review, we first discuss the role of NO in the pathobiology of lung fibrosis and the technique currently approved for the measurement of maximum bronchial flux of NO (J'awNO) and alveolar concentration of NO (CaNO). We systematically report the published evidence regarding extended FeNO analysis in the management of patients with different ILDs, focusing on its potential role in differential diagnosis, prognostic evaluation and severity assessment of disease. The few available data concerning extended FeNO analysis, and the most common comorbidities of ILD, are explored too. In conclusion, multiple-flows FeNO analysis, and CaNO in particular, appears to be a promising tool to be implemented in the diagnostic and prognostic pathways of patients affected with ILDs.

Clinical and Functional Characteristics of Patients with Unclassifiable Interstitial Lung Disease (uILD): Long-Term Follow-Up Data from European IPF Registry (eurIPFreg)

(1) Aim of the study: In spite of extensive research, up to 20% of interstitial lung diseases (ILD) patients cannot be safely classified. We analyzed clinical features, progression factors, and outcomes of unclassifiable ILD (uILD). (2) Methods: A total of 140 uILD subjects from the University of Giessen and Marburg Lung Center (UGMLC) were recruited between 11/2009 and 01/2019 into the European Registry for idiopathic pulmonary fibrosis (eurIPFreg) and followed until 01/2020. The diagnosis of uILD was applied only when a conclusive diagnosis could not be reached with certainty. (3) Results: In 46.4% of the patients, the uILD diagnosis was due to conflicting clinical, radiological, and pathological data. By applying the diagnostic criteria of usual interstitial pneumonia (UIP) based on computed tomography (CT), published by the Fleischner Society, 22.2% of the patients displayed a typical UIP pattern. We also showed that forced vital capacity (FVC) at baseline (p = 0.008), annual FVC decline ≥10% (p < 0.0001), smoking (p = 0.033), and a diffusing capacity of the lung for carbon monoxide (DLco) ≤55% of predicted value at baseline (p < 0.0001) were significantly associated with progressive disease. (4) Conclusions: The most important prognostic factors in uILD are baseline level and decline in lung function and smoking. The use of Fleischner diagnostic criteria allows further differentiation and accurate diagnosis.

Obstructive sleep apnea in patients with interstitial lung disease: Prevalence and predictive factors

Interstitial lung diseases (ILDs) are chronic, progressive, parenchymal lung diseases with high morbidity and mortality. In recent studies, the prevalence of obstructive sleep apnea (OSA) in patients with ILD has been reported to be high. However, the prevalence and predictive factors of OSA in Korean ILD patients are not well defined. Therefore, the aim of this study was to evaluate the prevalence and predictive factors of OSA in Korean patients with ILD. Clinical data from 86 patients with ILD enrolled from December 2017 to April 2019 at Haeundae-Paik Hospital, Busan, South Korea, were retrospectively analyzed. OSA was monitored with a level 4 portable device and defined as an apnea-hypopnea index of more than 5 per hour of sleep. The median follow-up period was 7 months. The mean age was 69.8 years, and 64% of participants were men. Among the ILDs, idiopathic pulmonary fibrosis (IPF) was the most common (66.3%), followed by connective tissue disease-associated ILD (16.3%) and cryptogenic organizing pneumonia (5.8%). Forty-six ILD patients (53.5%) were diagnosed with OSA, and IPF patients had OSA more frequently (64.9% vs. 31.0%, p = 0.003) than those with other ILDs. Older age (odds ratio [OR], 1.11, 95% CI 1.04-1.19, p = 0.002), higher body weight (OR 1.05, 95% CI 1.01-1.10, p = 0.012), and diabetes mellitus (OR 4.03, 95% CI 1.26-12.91, p = 0.019) were independent risk factors for OSA in the multivariable logistic regression analysis. In the multivariable Cox analysis, an IPF diagnosis was a significant risk factor for one-year mortality (hazard ratio [HR] 7.92, 95% CI: 1.01-61.83, p = 0.048) in ILD patients; however, OSA was not. In conclusion, half of Korean patients with ILD had OSA. Older age, higher body weight, and diabetes mellitus were risk factors for OSA in patients with ILD.

First Description of the Hyperpnea-Hypopnea Periodic Breathing in Patients with Interstitial Lung Disease-Obstructive Sleep Apnea: Treatment Implications in a Real-Life Setting

There is evidence that hypopneas are more common than apneas in obstructive sleep apnea (OSA) related to idiopathic pulmonary fibrosis (IPF). We investigated the frequency distribution of hypopneas in 100 patients with interstitial lung diseases (ILDs) (mean age 69 yrs ± 7.8; 70% males), including 54 IPF cases, screened for OSA by home sleep testing. Fifty age- and sex-matched pure OSA patients were included as controls. In ILD-OSA patients the sleep breathing pattern was characterized by a high prevalence of hypopneas that were preceded by hyperpnea events configuring a sort of periodic pattern. This finding, we arbitrarily defined hyperpnea–hypopnea periodic breathing (HHPB), was likely reflecting a central event and was completely absent in control OSA. Also, the HHPB was highly responsive to oxygen but not to the continuous positive pressure support. Thirty-three ILD-OSA patients (42%) with a HHPB associated with a hypopnea/apnea ratio ≥3 had the best response to oxygen with a median residual AHI of 2.6 (1.8–5.6) vs. 28.3 (20.7–37.8) at baseline (p < 0.0001). ILD-OSA patients with these characteristics were similarly distributed in IPF (54.5%) and no-IPF cases (45.5%), the most of them being affected by moderate–severe OSA (p = 0.027). Future studies addressing the pathogenesis and therapy management of the HHPB should be encouraged in ILD-OSA patients.

The prevalence of poor sleep quality and its associated factors in patients with interstitial lung disease: a cross-sectional analysis

Background

Many patients with interstitial lung disease (ILD) experience poor sleep quality, which may contribute to decreased quality of life. Sleep disordered breathing is commonly associated with ILD but there is less information on other factors that may contribute to poor sleep quality.

Methods

We conducted a cross-sectional analysis of 101 patients with a diagnosis of ILD at a pulmonary rehabilitation assessment clinic. We assessed the prevalence of poor sleep quality using the Pittsburgh Sleep Quality Index (PSQI) and performed multivariable logistic regression analysis to determine factors independently associated with poor sleep quality.

Results

Median forced expiratory volume in 1 s was 64% predicted (interquartile range (IQR) 50–77%) and vital capacity was 62% predicted (IQR 48–78%). 67 (66%) out of 101 patients reported poor sleep quality. The median PSQI was 8 units (IQR 4–11 units). There were no significant differences in physical or physiological parameters including age, sex distribution, body mass index or spirometry values between subjects with good sleep quality and those with poor sleep quality (all p>0.1). Multivariable logistic regression showed that depression (p=0.003) and Epworth Sleepiness Scale (p=0.03) were independently associated with poor sleep quality.

Conclusion

Poor sleep quality is common in patients with ILD and is independently associated with increasing symptoms of depression and sleepiness. Routine assessment of sleep quality should be undertaken and interventions targeting depression and coexisting sleep disorders may be required in symptomatic patients to determine if sleep quality and ultimately, health-related quality of life improves as a result.

Poor sleep quality is common in patients with interstitial lung disease and is independently associated with increasing symptoms of depression and sleepinesshttp://bit.ly/2WeQbzw

Relation of Warrick Score and Polysomnographic Parameters in Patients with Interstitial Lung Disease

Background

Obstructive sleep apnea (OSA) is often reported in connection with interstitial lung disease. As yet, there is insufficient data on the association of OSA severity parameters with lung involvement. We purposed to assess the frequency of OSA in our study group and to investigate the relationship between radiological involvement and OSA severity parameters.

Material/Methods

The study included 79 patients with interstitial lung disease who underwent spirometry, a carbon monoxide diffusion test (DLCO), high-resolution computed tomography, and polysomnography. The data were analyzed using SPSS 22 software.

Results

Of the 79 patients, 53 patients (67.1%) had OSA, and there was a negative correlation between DLCO and the mean time spent with oxygen saturation levels below 90% (r=−0.686, P=0.001). The Warrick score was used as an indicator of the extent and severity of pulmonary involvement and was positively correlated with the apnea-hypopnea index, oxygen desaturation index, and the mean time spent with oxygen saturation below 90% (r=0.275, P=0.014; r=0.264 P=0.019; r=0.235, P=0.038).

Conclusions

In our study, a significant relationship was found between the Warrick score and the OSA severity parameters, as determined by polysomnography. Polysomnographic examinations might be useful, especially in patients with a Warrick score greater than 15, to avoid possible complications.

Management of Chronic Respiratory Failure in Interstitial Lung Diseases: Overview and Clinical Insights

Interstitial lung diseases (ILDs) may be complicated by chronic respiratory failure (CRF), especially in the advanced stages. Aim of this narrative review is to evaluate the current evidence in management of CRF in ILDs. Many physiological mechanisms underlie CRF in ILDs, including lung restriction, ventilation/perfusion mismatch, impaired diffusion capacity and pulmonary vascular damage. Intermittent exertional hypoxemia is often the initial sign of CRF, evolving, as ILD progresses, into continuous hypoxemia. In the majority of the cases, the development of CRF is secondary to the worsening of the underlying disease; however, associated comorbidities may also play a role. When managing CRF in ILDs, the need for pulmonary rehabilitation, the referral to lung transplant centers and palliative care should be assessed and, if necessary, promptly offered. Long-term oxygen therapy is commonly prescribed in case of resting or exertional hypoxemia with the purpose to decrease dyspnea and improve exercise tolerance. High-Flow Nasal Cannula oxygen therapy may be used as an alternative to conventional oxygen therapy for ILD patients with severe hypoxemia requiring both high flows and high oxygen concentrations. Non-Invasive Ventilation may be used in the chronic setting for palliation of end-stage ILD patients, although the evidence to support this application is very limited.

Obstructive sleep apnoea in patients with fibrotic diffuse parenchymal lung disease-characterization and treatment compliance assessment

INTRODUCTION

Recent studies have reported a high prevalence of obstructive sleep apnoea (OSA) among patients with diffuse parenchymal lung disease (DPLD), mainly idiopathic pulmonary fibrosis (IPF). Effective OSA treatment appears to have a positive impact on morbidity and mortality in these patients. However, poor compliance to positive airway pressure (PAP) treatment in fibrotic DPLD patients has been reported. The aims of our study were to characterize patients with fibrotic DPLD and OSA and to assess their compliance to PAP treatment.

METHODS

Forty-nine patients with fibrotic DPLD underwent level III polysomnography. Auto-adjusting PAP (APAP) treatment was proposed for those patients with moderate-to-severe OSA and those with mild OSA with daytime sleepiness and/or cardiovascular disease. The APAP treatment compliance was assessed after 1 month of therapy.

RESULTS

The distribution of the 49 fibrotic DPLD patients included was as follows: 21 with chronic hypersensitivity pneumonitis, 12 with IPF, 10 with connective-tissue associated DPLD, 4 with stage IV sarcoidosis, 1 with idiopathic pleuropulmonary fibroelastosis, and 1 with DPLD-associated vasculitis. Thirty-four (69.4%) of the patients presented with OSA; 22 had mild OSA, and 12 had moderate-to-severe OSA. APAP treatment was prescribed in 17 of the patients. After 1 month of therapy, all patients used APAP more than 70% of the nights for more than 4 h per night.

CONCLUSION

We found a high prevalence of OSA among all of the patients with fibrotic DPLD (not only IPF). Despite certain difficulties, it was possible to achieve good APAP compliance in these patients.

Daily variation of gene expression in diverse rat tissues

Circadian information is maintained in mammalian tissues by a cell-autonomous network of transcriptional feedback loops that have evolved to optimally regulate tissue-specific functions. An analysis of daily gene expression in different tissues, as well as an evaluation of inter-tissue circadian variability, is crucial for a systems-level understanding of this transcriptional circuitry. Affymetrix gene chip measurements of liver, muscle, adipose, and lung tissues were obtained from a rich time series light/dark experiment, involving 54 normal rats sacrificed at 18 time points within the 24-hr cycle. Our analysis revealed a high degree of circadian regulation with a variable distribution of phases among the four tissues. Interestingly, only a small number of common genes maintain circadian activity in all tissues, with many of them consisting of "core-clock" components with synchronous rhythms. Our results suggest that inter-tissue circadian variability is a critical component of homeostatic body function and is mediated by diverse signaling pathways that ultimately lead to highly tissue-specific transcription regulation.