Sleep disturbances and health-related quality of life in adults with steady-state bronchiectasis

The prevalence of anxiety in respiratory and sleep diseases: A systematic review and meta-analysis

BACKGROUND

Anxiety is common in those with chronic physical health conditions and can have significant impacts on both quality of life and physical health outcomes. Despite this, there are limited studies comprehensively investigating the prevalence of anxiety in respiratory and sleep medicine settings. This systematic review and meta-analysis aims to provide insight into the global prevalence of anxiety symptoms/disorders in respiratory and sleep medicine outpatients.

METHODS

PubMed, Embase, Cochrane, PsycINFO and Google Scholar databases were searched from database inception to January 23, 2023 for studies assessing the prevalence of anxiety in adult (≥16 years) respiratory and sleep medicine outpatients. Data was screened and extracted independently by two investigators. Anxiety was measured using various self-report questionnaires, structured interviews, and/or patient records. Using CMA software for the meta-analysis, a random-effects model was used for pooled estimates, and subgroup analysis was conducted on relevant models using a mixed-effects model.

RESULTS

116 studies were included, featuring 36,340 participants across 40 countries. The pooled prevalence of anxiety was 30.3 % (95%CI 27.9-32.9 %, 10,679/36,340). Subgroup analysis found a significant difference across type of condition, with pulmonary tuberculosis the highest at 43.1 % and COVID-19 outpatients the lowest at 23.4 %. No significant difference was found across anxiety types, country or age. Female sex and the use of self-report measures was associated with significantly higher anxiety estimates.

CONCLUSIONS

Anxiety is a common experience amongst patients in respiratory and sleep medicine outpatient settings. Thus, it is crucial that anxiety identification and management is considered by physicians in the field.

REGISTRATION

The protocol is registered in PROSPERO (CRD42021282416).

Frequency of Obstructive Sleep Apnea in Patients With Cystic Fibrosis and Non-cystic Fibrosis Bronchiectasis and Its Association With Clinical Findings

OBJECTIVE

This study was designed to assess obstructive sleep apnea (OSA) in adult patients with cystic fibrosis (CF) and non-CF bronchiectasis (BE) and to relate it with clinical characteristics.

METHODS

Thirty-five CF (27 years) and 35 non-CF (24 years) BE patients were included. Demographic characteristics, medications, comorbidities, BMI, dyspnea scales, pulmonary functions, sputum cultures, exacerbations, and hospitalizations were recorded. The Epworth Sleepiness Scale (ESS) questionnaire was filled and polysomnography was performed for each patient.

RESULTS

ESS scores did not show any significant difference between CF and non-CF BE patients. Thirty-seven (53%) of all patients had OSA. There was no significant difference in OSA risk between CF and non-CF BE patients (54% vs 51%, respectively). Male gender was found to be a risk factor for OSA (68% of males vs 41% of females, respectively, p:0.026). Total sleep time, sleep efficiency, sleep latency, time spent awake after falling asleep, oxygen desaturation index, apnea-hypopnea-index (AHI), AHI in the supine position, and rapid eye movement phase did not show any significant difference between CF and non-CF patients. CF patients had significantly lower mean oxygen saturation (p:0.001) and lowest oxygen saturation (p:0.0024) levels and higher heart rate (p:0.02) compared to non-CF BE patients. Multiple logistic regression analysis of all patients revealed male gender and disease duration as risk factors for OSA (p:0.023 and p:0.041 respectively).

CONCLUSION

It is remarkable that more than half of the patients in both CF and non-CF bronchiectasis groups had OSA. Male gender and disease duration were found as risk factors for OSA.

Sleep-Disordered Breathing and Chronic Respiratory Infections: A Narrative Review in Adult and Pediatric Population

Sleep-disordered breathing (SDB) comprises different diseases characterized by abnormal respiratory patterns during sleep including obstructive sleep apnea. SDB prevalence and impact in patients with chronic respiratory infections have been only marginally studied. The purpose of this narrative review is to report the prevalence and impact of SDB in chronic respiratory infections, including cystic fibrosis (CF), bronchiectasis and mycobacterial infections, and explore the possible pathophysiological mechanisms. Common pathophysiological mechanisms, underlying SDB onset in all chronic respiratory infections, include inflammation, which plays a central role, chronic nocturnal cough and pain, excessive production of mucous plugs, presence of obstructive and/or restrictive ventilatory impairment, upper airways involvement, and comorbidities, such as alteration of nutritional status. SDB may affect about 50% of patients with bronchiectasis. The severity of the disease, e.g., patients colonized with P. aeruginosa and frequent exacerbators, as well as comorbidities, such as chronic obstructive pulmonary disease and primary ciliary dyskinesia, may impact SDB onset. SDB may also frequently complicate the clinical course of both children and adults with CF, impacting the quality of life and disease prognosis, suggesting that their routine assessment should be incorporated into the clinical evaluation of patients from the first stages of the disease regardless of suggestive symptoms, in order to avoid late diagnosis. Finally, although the prevalence of SDB in patients with mycobacterial infections is uncertain, extrapulmonary manifestations, particularly nasopharyngeal locations, and concomitant symptoms, such as body pain and depression, may act as atypical predisposing factors for their development.

The Bronchiectasis in COPD-OSA Overlap Syndrome Patients

Purpose

COPD-OSA (chronic obstructive pulmonary disease–obstructive sleep apnea) overlap syndrome is associated with more frequent COPD acute exacerbations than COPD without OSA. With the application of high-resolution computed tomography (HRCT) in COPD, bronchiectasis is commonly detected and is associated with disease severity. Sleep respiratory disease is also associated with bronchiectasis; however, the correlation between OSA and coexisted bronchiectasis in COPD (COPD-Bx) has not been reported yet.

Patients and Methods

A total of 124 consecutive patients with stable COPD were enrolled. All subjects completed the chest HRCT and nocturnal polysomnography (PSG). The scores of extent and severity in bronchiectasis were assessed based on the Smith method and the Bhalla scoring system. Clinical data, questionnaire, routine blood test data, blood levels of C-reactive protein (CRP) and Immunoglobulin E, and the lymphocyte subtype were collected.

Results

Among all enrolled patients, 56.45% (70/124) were diagnosed as COPD-OSA based on the results of PSG screening. Bronchiectasis was detected in 42.86% (30/70) of the patients with COPD-OSA, but in 18.52% (10/54) of the patients without OSA (χ2=8.264, p=0.004). PSG screening revealed that COPD with OSA had a significantly higher apnea-hypopnea index and percent of time spent with oxygen saturation below 90% (T90). Higher values of CRP, T90, and lower CD4/CD8 in the COPD-Bx with OSA were detected compared to COPD-Bx without OSA. Correlation analysis showed that the Bhalla severity score was related to CD8 cell count (r=0.446, p<0.05) and CD4/CD8 (r=−0.357, p<0.05) in all the COPD-Bx patients. The Smith extent score was also associated with the values of CD8 count (r=0.388, p<0.05) and CD4/CD8 (r=−0.381, p<0.05).

Conclusion

The comorbid bronchiectasis was more common in COPD-OSA overlap syndrome patient and may be related to more severe hypoxia and increased systemic inflammation.

Exercise capacity in patients with cystic fibrosis vs. non-cystic fibrosis bronchiectasis

Background

Bronchiectasis is associated with morbidity, low exercise capacity and poor quality of life. There is a paucity of data on exercise capacity using cardiopulmonary exercise test (CPET) in non-cystic fibrosis (CF) bronchiectasis. Our aim was to compare exercise capacity using CPET in CF and non-CF bronchiectasis patients.

Methods

Cross-sectional retrospective/prospective controlled study assessing CPET using cycle ergometer. Exercise parameters and computed tomography (CT) findings were compared. Results: Hundred two patients with bronchiectasis and 88 controls were evaluated; 49 CF (age 19.7 ± 9.7 y/o, FEV₁%predicted 70.9 ± 20.5%) and 53 non-CF (18.6 ± 10.6 y/o, FEV₁%predicted 68.7 ± 21.5%). Peak oxygen uptake (peak V˙O2) was similar and relatively preserved in both groups (CF 1915.5±702.0; non-CF 1740±568; control 2111.0±748.3 mL/min). Breathing limitation was found in the two groups vs. control; low breathing reserve (49% in CF; 43% non-CF; 5% control) and increased V˙E/V˙CO2 (CF 31.4±4.1, non-CF 31.7±4.1 and control 27.2 ± 2.8). Oxygen pulse was lower in the non-CF; whereas a linear relationship between peak V˙O2 vs. FEV₁ and vs. FVC was found only for CF. CT score correlated with V˙E/V˙CO2 and negatively correlated with V˙O2/kg and post exercise oxygen saturation (SpO₂).

Conclusions

CPET parameters may differ between CF and non-CF bronchiectasis. However, normal exercise capacity may be found unrelated to the etiology of the bronchiectasis. Anatomical changes in CT are associated with functional finding of increased V˙E/V˙CO2 and decreased SpO₂. Larger longitudinal studies including cardiac assessment are needed to better study exercise capacity in different etiologies of non-CF bronchiectasis.

Trial registration

ClinicalTrials.gov, registration number: NCT03147651.

A randomized trial to determine the impact of indacaterol/glycopyrronium on nighttime oxygenation and symptoms in patients with moderate-to-severe COPD: the DuoSleep study

PURPOSE

This study investigated the effect of dual bronchodilation with the long-acting β-receptor agonist/long-acting muscarinic antagonist combination, indacaterol/glycopyrronium (IND/GLY), on nighttime oxygenation, lung function, sleep quality, and symptoms in patients with moderate-to-severe COPD.

PATIENTS AND METHODS

This was a 4-week, double-blind, multicenter, placebo-controlled, two-period crossover study. Patients were randomized in a 1:1 ratio to receive IND/GLY 110/50 µg once daily or matching placebo. The primary objective was to evaluate the effect of treatment with IND/GLY on mean nighttime oxygenation, compared with placebo. The secondary objective was to determine the time spent <90% in blood oxygen saturation (SpO2) compared with placebo. Exploratory objectives were to assess the effect of IND/GLY, compared with placebo, on sleep quality measured by the Medical Outcomes Study (MOS) Sleep Scale and the COPD and Asthma Sleep Impact Scale (CASIS) questionnaires and on symptoms assessed by COPD Assessment Test (CAT) questionnaire.

RESULTS

In total, 38 patients were randomized (n=22, IND/GLY; n=16, placebo). The change in nighttime oxygenation (SpO2) was similar, and there was a comparable difference in time spent <90% SpO2 between IND/GLY and placebo. Increases from baseline for the difference between IND/GLY and placebo for trough FEV1, FVC, and inspiratory capacity (P<0.05) were seen, with a corresponding reduction in residual volume and functional residual capacity (P<0.05). IND/GLY treatment showed an improvement in scores for CAT (P=0.0208), CASIS, and the MOS Sleep Scale measures, Sleep Problems Index I, Sleep Problems Index II (P=0.0315), Sleep Adequacy, Sleep Disturbance Scale, Somnolence Scale, and Short of Breath Scale (P=0.0031).

CONCLUSION

In this study, IND/GLY 110/50 µg once daily improved symptoms, sleep quality, and lung function, but showed no effect on nighttime oxygenation in patients with moderate-to-severe COPD.

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.

Evaluation of obstructive sleep apnea in non-cystic fibrosis bronchiectasis: A cross-sectional study

The relationship between sleep disorders and bronchiectasis has not been well described. We hypothesize that, due to the irreversible dilatation of the bronchi, the presence of secretions, and airflow obstruction, patients with non-cystic fibrosis bronchiectasis may be predisposed to hypoxemia during sleep, or to symptoms that may lead to arousal. A cross-sectional observational study was performed involving 49 patients with a clinical diagnosis of non-cystic fibrosis bronchiectasis (NCFB). All patients underwent clinical evaluation, spirometry, and polysomnography, and were evaluated for the presence of excessive daytime sleepiness (EDS) and risk of obstructive sleep apnea (OSA). The mean age of the participants was 50.3 ± 13.6 years; 51.1% of patients were male and had a mean body mass index of 23.8 ± 3.4 kg/m². The mean total sleep time (TST) was 325.15 ± 64.22 min with a slight reduction in sleep efficiency (84.01 ± 29.2%). Regarding sleep stages, stage 1 sleep and REM sleep were abnormal. OSA was present in 40.82% of the patients. The mean arousal index was 5.6 ± 2.9/h and snoring was observed in 71.43% of the patients. The oxygen desaturation index (ODI) was 14.35 ± 15.36/h, mean minimum oxygen saturation (SpO₂ nadir) was 83.29 ± 7.99%, and mean TST with an SpO₂ less than 90% was 30.21 ± 60.48 min. EDS was exhibited by 53.06% of the patients and 55.1% were at high risk of developing OSA. The patients infected by Pseudomonas aeruginosa had higher apnea-hypopnea indices, ODI, and TST with SpO₂ < 90%, and lower values of SpO₂ nadir. Adult patients with clinically stable NCFB, especially those infected by Pseudomonas aeruginosa, display EDS and a high prevalence of OSA, associated with considerable oxygen desaturation during sleep.

Relationship between sleep quality and mental health according to demographics of 850 patients with chronic obstructive pulmonary disease

We aimed to study sleep problems in hospitalized chronic obstructive pulmonary disease patients and assess the relationship of sleep quality with mental health and demographics of patients. Our study sample consisted of 850 chronic obstructive pulmonary disease patients hospitalized in Masih Daneshvari Hospital. Demographic data were collected and the Pittsburgh Sleep Quality and mental health questionnaires were filled out for patients. The results showed that 5.9 percent were suffering from severe sleep problems, while 4.7 percent had severe mental problems. A strong positive correlation was found between the total scores of mental health and sleep quality ( p < 0.01). The prevalence of sleep and mental health problems was higher in females compared to males. Mental health and sleep quality play important roles in quality of life of chronic obstructive pulmonary disease patients.

Measuring sleep quality in older adults: a comparison using subjective and objective methods

Sleep quality decreases with aging and thus sleep complaints are prevalent in older adults, particularly for those with cognitive impairment and dementia. For older adults, emerging evidence suggests poor sleep quality increases risk of developing cognitive impairment and dementia. Given the aging population-and the impending economic burden associated with increasing numbers of dementia patients-there is pressing need to improve sleep quality among older adults. As such, research efforts have increased focus on investigating the association between age-related sleep changes and cognitive decline in older adults. Sleep quality is a complex construct to evaluate empirically, and yet the Pittsburg Sleep Quality Index (PSQI) is commonly used in studies as their only measure of sleep quality. Furthermore, the PSQI may not be the best sleep quality measure for older adults, due to its reliance on the cognitive capacity to reflect on the past month. Further study is needed to determine the PSQI's validity among older adults. Thus, the current study examined sleep quality for 78 community dwelling adults 55+ to determine the PSQI's predictive validity for objective sleep quality (as measured by actigraphy). We compared two subjective measures of sleep quality-the PSQI and Consensus Sleep Diary (CSD)-with actigraphy (MotionWatch 8©; camntech). Our results suggest perceived sleep quality is quite different from objective reality, at least for adults 55+. Importantly, we show this difference is unrelated to age, gender, education, or cognitive status (assessed using standard screens). Previous studies have shown the PSQI to be a valuable tool for assessing subjective sleep quality; however, our findings indicate for older adults the PSQI should not be used as a substitute for actigraphy, or vice versa. Hence, we conclude best practice is to include both subjective and objective measures when examining sleep quality in older adults (i.e., the PSQI, CSD, and actigraphy).

Observational study of sleep, respiratory mechanics and quality of life in patients with non-cystic fibrosis bronchiectasis: a protocol study

INTRODUCTION

Bronchiectasis is a chronic disorder characterised by permanent and irreversible abnormal dilation of the bronchi and bronchioles, primarily caused by repeated cycles of pulmonary infections and inflammation, which lead to reduced mucociliary clearance and to the excessive production of sputum. Patients with non-cystic fibrosis bronchiectasis may be predisposed to hypoxemia during sleep, or to symptoms that may lead to arousals and thereby reduce the quality of life, because of the irreversible dilation of the bronchi and the presence of secretions and airflow obstruction.

METHODS AND ANALYSIS

For this cross-sectional observational study, patients with a clinical diagnosis of non-cystic fibrosis bronchiectasis will be recruited from the Bronchiectasis Clinic of the Pneumology Department of the Santa Casa de Misericordia Hospital and the Federal University of São Paulo (São Paulo, Brazil). Patients of either sex will be included if high-resolution CT of the thorax and classic sweat test confirms they have non-cystic fibrosis bronchiectasis, are between 18 and 80 years old, use long-acting bronchodilators, are clinically stable for a least 1 month, agree to participate in the study and they sign a statement of informed consent. The first part of the study will involve a clinical evaluation, maximal respiratory pressures, spirometry and the Saint George's Respiratory Questionnaire. The Sleep Laboratory of the Master's and Doctoral Postgraduate Program in Rehabilitation Sciences of the Nove de Julho University (São Paulo, Brazil) will perform the polysomnographic studies, Berlin Questionnaire, Epworth Sleepiness Scale, waist and neck circumferences, modified Mallampati classification and tonsil index.

ETHICS AND DISSEMINATION

This protocol has been approved by the Human Research Ethics Committees of Santa Casa de Misericordia Hospital (process number 178/2012) and Human Research Ethics Committee of Nove de Julho University (process number 370474/2010). All participants will sign a statement of informed consent. The study findings will be published in peer-reviewed journals and presented at conferences.

Six-minute walk test in Chinese adults with clinically stable bronchiectasis: association with clinical indices and determinants

BACKGROUND

The profiles of 6-minute walk distance (6MWD) in adults with clinically stable bronchiectasis in Chinese adult patients with bronchiectasis are unclear.

OBJECTIVES

To delineate the 6MWD by stratification of clinical indices, and to investigate the factors associated with reduced 6MWD in Chinese adults with clinically stable bronchiectasis.

METHODS

We recruited 141 adult bronchiectasis patients (mean age: 44.3 ± 13.9 years). Demography, radiology, spirometry, diffusing capacity, etiology, sputum bacteriology, modified Medical Research Council dyspnea scale (MMRC) and quality of life were assessed. The safety profile of the measurement was also examined.

RESULTS

Lower levels of 6MWD were associated with older age (>50 years), higher HRCT total score, presence of cystic bronchiectasis, bilateral bronchiectasis, reduced diffusing capacity, higher MMRC score, and higher SGRQ scores. Correlation coefficients between 6MWD and spirometry and quality of life scores were different in patients with 6MWD higher and lower than lower limit of normal. DLCO being less than 80% predicted (OR = 3.13, 95% CI: 1.32-7.43, P = 0.01) and MMRC scale between 1 and 4 (OR = 6.42, 95% CI: 2.27-18.18, P < 0.01) were the factors associated with 6MWD being less than the lower limit of normal (80% predicted value). No severe adverse events were reported.

CONCLUSION

The 6MWD could be safely measured in adult patients with bronchiectasis and is poorly associated with clinical parameters. DLCO less than 80% predicted and higher MMRC scale are independent predictors of 6MWD below the lower limit of normal. Our findings will provide a reference for management of bronchiectasis patients in mainland China.

When are we most vulnerable to temperature variations in a day?

Daily temperature measures are commonly used when examining the association between temperature and mortality. In fact, temperature measures are available 24 hours a day and more detailed records may provide a better prediction of mortality compared to daily statistics. In this article, monthly stratified analysis modeling for mortality is conducted for the total population as well as the stratified elderly and younger subgroups. We identified the most significant time during the day that is associated with daily mortality. Surprisingly, the estimates of relative risk and magnitude of associations derived from the hourly temperature measures are similar or even stronger compared to those modeled by the daily statistics. This phenomenon remains true for lagged hourly temperature measures and the changing patterns of associations from January through December are revealed. In summary, people are the most vulnerable to temperature variations in the early morning around 5 am and the night time around 8 pm.