Pulmonary rehabilitation improves sleep quality in chronic lung disease

Association between lung function and sleep disorder symptoms in a community-based multi-site case-finding study

Obstructive airway disease is associated with sleep disturbances. We aimed to assess the relationship between lung function and sleep disorder symptoms using cross-sectionally collected data between March 2017 and August 2021 from the Undiagnosed Chronic Obstructive Pulmonary Disease and Asthma Population study, a prospective community-based multi-site case-finding study. Undiagnosed Chronic Obstructive Pulmonary Disease and Asthma Population study participants with respiratory symptoms but without diagnosed lung disease who completed spirometry and the Global Sleep Assessment Questionnaire were included. We conducted multivariate linear regression models for forced expiratory volume in 1 s, forced vital capacity and forced expiratory volume in 1 s/forced vital capacity by Global Sleep Assessment Questionnaire responses adjusted for confounders. The same models were employed to examine respiratory symptoms, as reported on the St George's Respiratory Questionnaire and Chronic Obstructive Pulmonary Disease Assessment Test, by Global Sleep Assessment Questionnaire responses. Logistic regression models were used to assess the association of undiagnosed obstructive airway disease with sleep symptoms. Amongst 2093 adults included in the study, 48.3% were female and the median age was 63 years (interquartile range 53-72). Two-hundred and five (9.79%) subjects met spirometry criteria for undiagnosed chronic obstructive pulmonary disease, and 191 (9.13%) for undiagnosed asthma. There were no significant associations between spirometry measures and sleep symptoms (p > 0.5), controlling for age, sex, body mass index, smoking and comorbidities. Those with undiagnosed asthma were more likely to report insomnia "at least sometimes" versus "never" (odds ratio 2.58, 95% confidence interval: 1.27-6.19, p = 0.02). Respiratory symptoms were associated with sleep symptoms, with significant (p < 0.05) increases in St George's Respiratory Questionnaire and Chronic Obstructive Pulmonary Disease Assessment Test scores in those reporting most sleep symptoms. Overall, we found an association between undiagnosed asthma and insomnia, and between respiratory and sleep disorder symptoms.

Sleeve Gastrectomy is Associated with Longitudinal Improvements in Lung Function and Patient-Reported Respiratory Outcomes

PURPOSE

Obesity exerts negative effects on pulmonary function through proven mechanical and biochemical pathways. Multiple studies have suggested that bariatric surgery can improve lung function. However, the timing of these effects on lung function and its association with patient reported outcomes is not known.

MATERIALS AND METHODS

A prospective cohort study of patients undergoing laparoscopic sleeve gastrectomy (LSG) at a tertiary care hospital was undertaken. Spirometry tests, laboratory tests, and self-reported questionnaires on asthma symptoms and asthma control (ACQ and ACT) were administered. All data were recorded pre-operatively (T0) and every 3 months post-operatively for 1 year (T3, T6, T9, T12) and were compared using a mixed-models approach for repeated measures.

RESULTS

For the 23 participants, mean age was 44.2 ± 12.3 years, mean BMI was 45.2 ± 7.2 kg/m2, 18(78%) were female, 9(39%) self-reported as non-white and 6(26%) reported to have asthma. Following LSG, % total body weight loss was significant at all follow-up points (P < 0.0001). Rapid improvement in forced expiratory volume (FEV)% predicted and forced vital capacity (FVC)% predicted was seen at T3. Although the overall ACQ and ACT score remained within normal range throughout the study, shortness of breath declined significantly at 3 months post-op (P < 0.05) and wheezing resolved for all patients by twelve months. Patients also reported reduced frequency of sleep interruption and inability to exercise by the end of the study (P < 0.05).

CONCLUSION

Improvements in objective lung function assessments and patient-reported respiratory outcomes begin as early as 3 months and continue until 12 months after sleeve gastrectomy.

The Overlap Syndrome: A Combination of Chronic Obstructive Pulmonary Disease and Obstructive Sleep Apnea

Chronic obstructive pulmonary disease (COPD) is a severe lung disease that results in persistent and progressively worsening airflow obstruction due to abnormalities in the airway and alveoli. Obstructive sleep apnea (OSA) is a critical condition characterized by obstructive apneas, hypopneas, and respiratory effort-related arousals. These events occur due to the repetitive collapse of the upper airway during sleep, and it is essential to address this condition. These two conditions, when co-occur, are known as overlap syndrome (OS), which is associated with a higher likelihood of morbidity and mortality compared to either condition alone. Effective management of overlap syndrome is critical to maintain normal oxygen levels during sleep and reduce the incidence of hypoxemia and hypoventilation while improving sleep quality. Positive pressure ventilation is a standard technique used to effectively lower hospitalizations, emergency room visits, moderate and severe exacerbations, and related healthcare expenses in patients diagnosed with COPD and OSA. Despite the lack of literature on overlap syndrome, it is imperative to understand that this condition requires prompt and effective management to prevent further complications. Therefore, this review provides a detailed discussion highlighting the importance of proactive measures to manage overlap syndrome.

Poor sleep is associated with deficits of attention in COPD patients

BACKGROUND

Poor sleep and attention deficits are common in COPD.

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

Pulmonary rehabilitation improves sleep efficiency measured by actigraphy in poorly sleeping COPD patients

Chronic insomnia is reported by up to 50% of chronic obstructive pulmonary disease (COPD) patients. This may be attributable to several factors including nocturnal dyspnea, reduced physical activity, and less time outside. Pulmonary rehabilitation (PR) is recommended in COPD to improve both physical and psychological conditioning. The aim of this study was to assess the effect of PR on sleep efficiency (SE, measured by actigraphy) in COPD patients. COPD eligible for PR were prospectively included. Baseline and post PR (30 sessions) assessments included incremental and maximal exercise testing, 6-min walking distance test (6MWT), actigraphy, and questionnaires [Pittsburgh Sleep Quality Index (PSQI), Hospital Anxiety Depression scale, St George Respiratory, and modified Medical Research Council dyspnea scale]. Sixty-one patients were included, and 31 patients completed the study protocol (68% of males, age 63 ± 9 y, FEV1 44.2 ± 12.3%). After PR, SE remained unchanged, p = 0.07, as well as PSQI score (p = 0.22), despite improvements in exercise capacity (incremental exercise test, 6MWT) and dyspnea. However, SE improved significantly in the poor sleeper subgroup (SE < 85%, n = 24, p = 0.02), whereas the PSQI remained unchanged. The present study shows, in COPD patients included in a PR program, that improvement in exercise capacity was disappointingly not associated with a better SE assessed by actigraphy. Subjective sleep quality was also unchanged at the end of PR program. However, SE improved significantly in the poor sleeper subgroup (SE < 85%). Further studies are required to better characterize the origin of sleep disturbances in COPD and the potential benefit of some (non-)pharmacologic interventions.

PIF1 Promotes Autophagy to Inhibit Chronic Hypoxia Induced Apoptosis of Pulmonary Artery Endothelial Cells

Purpose

Pulmonary artery hypertension (PAH) is a common complication of chronic obstructive pulmonary disease and obstructive sleep apnea/hypopnea syndrome worldwide. Pulmonary vascular alterations associated with PAH have multifactorial causes, in which endothelial cells play an important role. Autophagy is closely related to endothelial cell injury and the development of PAH. PIF1 is a multifunctional helicase crucial for cell survival. The present study investigated the effect of PIF1 on autophagy and apoptosis in human pulmonary artery endothelial cells (HPAECs) under chronic hypoxia stress.

Methods

Chronic hypoxia Gene expression profiling chip-assays identified the PIF1 gene as differentially expressed, which was verified by RT-qPCR analysis. Electron microscopy, immunofluorescence, and Western blotting were used to analyze autophagy and the expression of LC3 and P62. Apoptosis was analyzed using flow cytometry.

Results

Our study found that chronic hypoxia induces autophagy in HPAECs, and apoptosis was exacerbated by inhibiting autophagy. Levels of the DNA helicase PIF1 were increased in HPAECs after chronic hypoxia. PIF1 knockdown inhibited autophagy and promoted the apoptosis of HPAECs under chronic hypoxia stress.

Conclusion

Based on these findings, we conclude that PIF1 inhibits the apoptosis of HPAECs by accelerating the autophagy pathway. Therefore, PIF1 plays a crucial role in HPAEC dysfunction in chronic hypoxia-induced PAH and may be a potential target for the treatment of PAH.

Impact of cardiorespiratory rehabilitation program on submaximal exercise capacity of Tunisian male patients with post-COVID19: A pilot study

Post-COVID19 patients suffer from persistent respiratory, cardiovascular, neurological, and musculoskeletal health complaints such as dyspnea, chest pain/discomfort, and fatigue. In Tunisia, the potential benefits of a cardiorespiratory rehabilitation program (CRRP) after COVID19 remain unclear. The main aim of this study was to evaluate the impact of a CRRP on submaximal exercise capacity, evaluated through the 6-min walk test (6MWT) data in post-COVID19 Tunisian patients. This was a cross-sectional study including 14 moderate to severe COVID19 patients aged from 50 to 70 years. CRRP was performed after the end of patients’ hospitalization in COVID19 units for extensive or severe extents of COVID19. Dyspnea (modified medical research council), spirometry data, handgrip strength values, 6MWT data, and 6-min walk work (i.e., 6-min walk distance x weight) were evaluated 1-week pre-CRRP, and 1-week post-CRRP. CRRP included 12 sessions [3 sessions (70 min each)/week for 4 weeks]. Exercise-training included aerobic cycle endurance, strength training, and educational sessions. Comparing pre- and post- CRRP results showed significant improvements in the means±standard deviations of dyspnea by 1.79 ± 0.80 points (p < 0.001), forced expiratory volume in one second by 110 ± 180 ml (p = 0.04), 6-min walk distance by 35 ± 42 m (p = 0.01), 6-min walk work by 2,448 ± 3,925 mkg (p = 0.048), resting heart-rate by 7 ± 9 bpm (p = 0.02) and resting diastolic blood pressure by 6 ± 10 mmHg (p = 0.045). In Tunisia, CRRP seems to improve the submaximal exercise capacity of post-COVID19 patients, mainly the 6-min walk distance and work.

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.

Chronic breathlessness and sleep problems: a population-based survey

OBJECTIVES

This study aimed to explore the relationship (presence and severity) between chronic breathlessness and sleep problems, independently of diagnoses and health service contact by surveying a large, representative sample of the general population.

SETTING

Analysis of the 2017 South Australian Health Omnibus Survey, an annual, cross-sectional, face-to-face, multistage, clustered area systematic sampling survey carried out in Spring 2017.Chronic breathlessness was self-reported using the ordinal modified Medical Research Council (mMRC; scores 0 (none) to 4 (housebound)) where breathlessness has been present for more than 3 of the previous 6 months. 'Sleep problems-ever' and 'sleep problem-current' were assessed dichotomously. Regression models were adjusted for age; sex and body mass index (BMI).

RESULTS

2900 responses were available (mean age 48.2 years (SD=18.6); 51% were female; mean BMI 27. 1 (SD=5.9)). Prevalence was: 2.7% (n=78) sleep problems-past; 6.8% (n=198) sleep problems-current and breathlessness (mMRC 1-4) was 8.8% (n=254). Respondents with sleep problemspast were more likely to be breathless, older with a higher BMI and sleep problems-present also included a higher likelihood of being female.After adjusting for age, sex and BMI, respondents with chronic breathlessness had 1.9 (95% CI=1.0 to 3.5) times the odds of sleep problems-past and sleep problems-current (adjusted OR=2.3; 95% CI=1.6 to 3.3).

CONCLUSIONS

There is a strong association between the two prevalent conditions. Future work will seek to understand if there is a causal relationship using validated sleep assessment tools and whether better managing one condition improves the other.

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.

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 deleterious effects of chronic obstructive pulmonary disease and obstructive sleep apnea: pathophysiology and implications on treatment

Background

Chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA) are both common in the adult population. The coexistence and association of both COPD and OSA have been described as the overlap syndrome. The scope of the present review is to address the magnitude, pathophysiology, clinical presentations, and the deleterious consequences of the coexistence of COPD and OSA in the same patient as well as the current management and treatment options of this association.

Main body of abstract

Epidemiological studies showed a prevalence of the overlap syndrome of up to 1% of the adult population. However, various studies agreed that this association is due to the fact that both COPD and OSA are common rather than an interaction of pathophysiology between the two affections. Nevertheless, sleep may cause adverse effects on breathing and lung functions. While these effects can be neglected in otherwise healthy individuals, they can lead in contrast to disastrous clinical outcomes particularly in vulnerable patients with the overlap syndrome leading to increased risk of cardiovascular diseases, acute COPD exacerbations, increased rates of hospitalizations, and nocturnal deaths. Current guidelines recommend polysomnography (PSG) as the gold standard investigation to diagnose sleep disorders and overlap syndrome. Treatment may include pulmonary rehabilitation, supplemental oxygen therapy, and non-invasive ventilation. Currently, continuous positive airway pressure (CPAP) therapy is the treatment of choice for the overlap syndrome. CPAP effects include improved respiratory mechanics; sleep quality, exercise tolerance, and prolonged survival.

Conclusion

Both COPD and OSA are common in the general population and present a significant risk of increased morbidity and mortality when they coexist in the same patient. Clinicians must carefully evaluate the clinical outcomes and the high risk of cardiovascular complications related to the overlap syndrome. Current data indicate that CPAP treatment leads to amelioration of the health-related quality of life and improve survival in patients with the overlap syndrome.

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.

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

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

The Effects of a Nurse-Led Education and Counseling Program on Dyspnea, Health Status, and Care Dependency in Patients With Chronic Obstructive Pulmonary Disease: A Feasibility Study

The aim of this feasibility study was to determine the effects of a nurse-led education and counseling program for chronic obstructive pulmonary disease (COPD-ECP) on dyspnea, health status, and care dependency in patients. A quasi-experimental, pre-posttest research design without a control group was performed on 30 COPD patients. The patients received an 8-week COPD-ECP via home visits during the first 4 weeks and via phone interviews in the subsequent 4 weeks. After completion of COPD-ECP and a 4-week break, a final follow-up was conducted at the end of 12th week. The Dyspnea-12, COPD Assessment Test (CAT), and Care Dependency Scale (CDS) scores were calculated during the first interview, and on the 4th, 8th, and 12th week of the study. The patients completed all sessions of COPD-ECP without side effects. There was a significant decrease in the total Dyspnea-12 scores at the end of the study period. Compared to the baseline assessment, CAT total scores significantly decreased in the 4th, 8th, and 12th week ( p < 0.05), and CDS scores showed a significant reduction at the 12th week ( p < 0.05). In conclusion, COPD-ECP is feasible in regular clinical practice and well accepted by patients, and it seems to improve health status and decrease dyspnea, and care dependency. Future randomized controlled studies are warranted to explore the effects of COPD-ECP on fatigue, cough and sleep problems, and the best innovative strategies to improve the efficiency of COPD-ECP.

Research Priorities in Pathophysiology for Sleep-disordered Breathing in Patients with Chronic Obstructive Pulmonary Disease. An Official American Thoracic Society Research Statement

BACKGROUND

Obstructive sleep apnea (OSA) and chronic obstructive pulmonary disease (COPD) are common conditions; the co-occurrence of these diseases, called the overlap syndrome (OVS), has been associated with poor health outcomes.

PURPOSE

The purpose of this Official American Thoracic Society Research Statement is to describe pathophysiology, epidemiology, outcomes, diagnostic metrics, and treatment of OVS, as well as to identify important gaps in knowledge and make recommendations for future research.

METHODS

Clinicians and researchers with expertise in sleep medicine, pulmonary medicine, or both were invited to participate. Topics were divided among the participants according to their interest and expertise. A literature search was conducted; the search was not a formal systematic review. Evidence was considered and supplemented with the panelists' nonsystematic clinical observations. Important knowledge gaps were identified.

RESULTS

Recommendations for research to fill existing knowledge gaps were made. The recommendations were formulated by discussion and consensus.

CONCLUSIONS

Many important questions about OVS exist. This American Thoracic Society Research Statement highlights the types of research that leading clinicians and researchers believe will have the greatest impact on better understanding the spectrum of disease, improving diagnosis, and optimizing therapy.

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 Overlap Syndrome

The overlap syndrome (OS) was first coined by David C. Flenley in 1985 to describe the coexistence of obstructive sleep apnea (OSA) in patients with chronic obstructive pulmonary disease (COPD). Patients with OS experience more profound nocturnal oxygen desaturation (NOD) than patients with OSA or COPD alone. This underlying hypoxia in OS increases the risk of cardiovascular disease including atrial fibrillation, right heart failure, and pulmonary hypertension, thereby increasing the mortality associated with the disease. Keeping in mind the risk of mortality, it is crucial for clinicians to clinically evaluate the patients with OSA or COPD for the occurrence of OS and provide effective treatment options for the same. This review aims to highlight the pathophysiology and the risks associated with the OS along with early detection and appropriate management protocols to reduce the mortality associated with it.

Sleep Disturbance in Smokers with Preserved Pulmonary Function and with Chronic Obstructive Pulmonary Disease

RATIONALE

Sleep disturbance frequently affects patients with chronic obstructive pulmonary disease (COPD), and is associated with reduced quality of life and poorer outcomes. Data indicate that smokers with preserved pulmonary function have clinical symptoms similar to those meeting spirometric criteria for COPD, but little is known about the driving factors for sleep disturbance in this population of emerging interest.

OBJECTIVES

To compare the magnitude and correlates of sleep disturbance between smokers with preserved pulmonary function and those with airflow obstruction.

METHODS

Using cross-sectional data from the COPD Outcomes-Based Network for Clinical Effectiveness and Research Translation multicenter registry, we identified participants clinically identified as having COPD with a smoking history of at least 20 pack-years and either preserved pulmonary function or airflow obstruction. We quantified sleep disturbance by T-score measured in the sleep disturbance domain of the Patient-Reported Outcomes Information System questionnaire, and defined a minimum important difference as a T-score difference of two points. We performed univariate and multivariable linear regression to evaluate correlates within each group.

RESULTS

We identified 100 smokers with preserved pulmonary function and 476 with airflow obstruction. The sleep disturbance T-score was 4.1 points greater among individuals with preserved pulmonary function (95% confidence interval [CI], 2.0-6.3). In adjusted analyses, depression symptom T-score was associated with sleep disturbance in both groups (airflow obstruction: β, 0.61 points; 95% CI, 0.27-0.94; preserved pulmonary function: β, 0.25 points; 95% CI, 0.12-0.38). Of note, lower percent predicted FEV₁ was associated with greater sleep disturbance among those with preserved pulmonary function (β, -0.19 points; 95% CI, -0.31 to -0.07), whereas higher FEV₁ was associated with greater sleep disturbance among individuals with airflow obstruction (β, 0.06 points; 95% CI, 0.01-0.10).

CONCLUSIONS

Among smokers with clinically identified COPD, the severity of sleep disturbance is greater among those with preserved pulmonary function compared with those with airflow obstruction. Nonrespiratory symptoms, such as depression, were associated with sleep disturbance in both groups, whereas the relationship of sleep disturbance with FEV₁ differed.

Exercise capacity and cancer-specific quality of life following curative intent treatment of stage I-IIIA lung cancer

PURPOSE

Lung cancer survivors are at risk for health impairments resulting from the effects and/or treatment of lung cancer and comorbidities. Practical exercise capacity (EC) assessments can help identify impairments that would otherwise remain undetected. In this study, we characterized and analyzed the association between functional EC and cancer-specific quality of life (QoL) in lung cancer survivors who previously completed curative intent treatment.

METHODS

In a cross-sectional study of 62 lung cancer survivors who completed treatment ≥ 1 month previously, we assessed functional EC with the 6-min walk distance (6MWD) and cancer-specific QoL with the European Organization for Research and Treatment of Cancer QoL Questionnaire Core 30 (EORTC-QLQ-C30). Cancer-specific QoL was defined using a validated composite EORTC-QLQ-C30 summary score. Univariable (UVA) and multivariable linear regression analyses (MVA) were performed to assess the relationship between functional EC and cancer-specific QoL.

RESULTS

Lung cancer survivors had reduced functional EC (mean 6MWD = 335 m, 65% predicted) and QoL (mean EORTC-QLQ-C30 summary score = 77, scale range 0-100). In UVA, 6MWD was significantly associated with cancer-specific QoL (R2 = 0.16, p = 0.001). In MVA, in a final model that also included heart failure, obstructive sleep apnea, and psychiatric illness, 6MWD was independently associated with cancer-specific QoL (partial R2 = 0.20, p = 0.001).

CONCLUSIONS

Functional EC was independently associated with cancer-specific QoL in lung cancer patients postcurative intent treatment. Exercise-based interventions aimed at improving EC may improve cancer-specific QoL in 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.

The effect of progressive muscle relaxation on the management of fatigue and quality of sleep in patients with chronic obstructive pulmonary disease: A randomized controlled clinical trial

OBJECTIVE

To assess the effect of progressive muscle relaxation (PMR) on fatigue and sleep quality of patients with chronic obstructive pulmonary disease (COPD) stages 3 and 4.

MATERIALS AND METHODS

The pretest posttest clinical trial recruited 91 patients COPD grades 3 and 4. Following random assignment of subjects, the treatment group (n = 45) performed PMR for eight weeks and the control group (n = 46) received routine cares. At baseline and after the intervention, fatigue and sleep quality was assessed. Data obtained were analyzed in SPSS.

RESULTS

It was determined that PMR decreased patients' fatigue level and improved some sleep quality subscales including subjective sleep quality, sleep latency, sleep duration and habitual sleep efficiency, but no improvement was found in global sleep quality and other sleep subscales.

CONCLUSION

An eight-week home-based PMR program can be effective in reducing fatigue and improving certain subscales of sleep quality in patients with COPD stages 3,4. (IRCT2016080124080N3).

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.

The effects a respiration rehabilitation program on IADL, satisfaction with leisure, and quality of sleep of patients with chronic obstructive pulmonary disease

[Purpose] This study was designed to determine the effect of a respiration rehabilitation program on daily activities, satisfaction with leisure, and quality of sleep of patients with chronic obstructive pulmonary disease. [Subjects and Methods] The program was conducted three times a week for 12 weeks (a total of 36 times) with 20 patients aged between 50 and 70 years old. The Frenchay Activity Index was used to determine the instrumental activities of daily living before and after the intervention. The Korean scale of satisfaction with leisure was employed to determine the satisfaction with leisure, and the Korean version of the Pittsburgh Sleep Quality Index was used to measure the quality of sleep. [Results] The total score of all three instruments (instrumental activities of daily living (IADL), satisfaction with leisure, and quality of sleep) improved significantly after the intervention. [Conclusion] In conclusion, the scores of all three instruments (IADL, satisfaction with leisure, and quality of sleep) improved significantly after the intervention, indicating that the respiration rehabilitation program was effective at improving the overall quality of life for patients with chronic obstructive pulmonary disease.

Sleep in Chronic Obstructive Pulmonary Disease: Evidence Gaps and Challenges

Chronic obstructive pulmonary disease (COPD) prevalence is rising to epidemic proportions due to historical smoking trends, the aging of the population, and air pollution. Although blaming the victims has been common in COPD, the majority of COPD worldwide is now thought to be nonsmoking related, that is, caused by air pollution and cookstove exposure. It is increasingly appreciated that subjective and objective sleep disturbances are common in COPD, although strong epidemiological data are lacking. People with obstructive sleep apnea (OSA) plus COPD (the so-called overlap syndrome) have a high risk of cardiovascular death, although again mechanisms are unknown and untested. This review aims to draw attention to the problem of sleep in COPD, to encourage clinicians to ask their patients about symptoms, and to stimulate further research in this area given the large burden of the disease.

On the cutting edge of obstructive sleep apnoea: where next?

Obstructive sleep apnoea is a common disease that is now more widely recognised because of the rise in prevalence and the increasingly compelling data that shows major neurocognitive and cardiovascular sequelae. At the same time, the clinical practice of sleep medicine is changing rapidly, with novel diagnostics and treatments that have established a home-based (rather than laboratory-based) management approach. We review the most recent insights and discoveries in obstructive sleep apnoea, with a focus on diagnostics and therapeutics. As will be discussed, management of obstructive sleep apnoea could soon transition from a so-called one size fits all approach to an individualised approach.

Frequent sputum production is associated with disturbed night's rest and impaired sleep quality in patients with COPD

Purpose

In this study, we measured night’s rest parameters measured with an accelerometer and sleep quality in mild to very severe patients with COPD. Furthermore, our aim was to investigate the association between night’s rest parameters and clinical variables and the association between sleep quality and quality of life or health status.

Methods

Mild to very severe COPD patients were recruited from general practitioners and outpatient clinics of general hospitals to participate in a cross-sectional study on physical activity in patients with COPD. A total of 103 patients (mean age 65 years, 67 % male) wore the accelerometer during night’s rest for at least four nights and were included in the analyses.

Results

No significant associations were found between objectively measured body movements during night’s rest or subjective sleep quality and lung function, dyspnoea severity, body composition and physical activity during the day. Patients with frequent sputum production during the day had a higher number of sitting transitions during the night (5.3 vs 4.3 sitting transitions) and more frequently got out of bed compared to patients who hardly ever produced sputum during the day (1.0 vs 0.8 times per night). Furthermore, these patients also reported worse sleep quality (Pittsburgh sleep quality index (PSQI) score 4 vs 3).

Conclusions

Our results indicate that objectively measured body movements during night’s rest like body postures and transitions are not related to sleep quality in patients with COPD. We did find an association between frequent sputum production and disturbances during night’s rest and sleep quality. Future studies should investigate whether the treatment of mucus hypersecretion leads to improved night’s rest.

Systematic literature review of patient-reported outcome measures used in assessment and measurement of sleep disorders in chronic obstructive pulmonary disease

BACKGROUND

Sleep problems are common in patients with chronic obstructive pulmonary disease (COPD), but the validity of patient-reported outcome measures (PROMs) that measure sleep dysfunction has not been evaluated. We have reviewed the literature to identify disease-specific and non-disease-specific sleep PROMs that have been validated for use in COPD patients. The review also examined the psychometric properties of identified sleep outcome measures and extracted point and variability estimates of sleep instruments used in COPD studies.

METHODS

The online EMBASE, MEDLINE, PsycINFO, and SCOPUS databases for all years to May 2014 were used to source articles for the review. The review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Criteria from the Medical Outcomes Trust Scientific Advisory Committee guidelines were used to evaluate the psychometric properties of all sleep PROMs identified.

RESULTS

One COPD-specific and six non-COPD-specific sleep outcome measures were identified and 44 papers met the review selection criteria. We only identified one instrument, the COPD and Asthma Sleep Impact Scale, which was developed specifically for use in COPD populations. Ninety percent of the identified studies used one of two non-disease-specific sleep scales, ie, the Pittsburgh Sleep Quality Index and/or the Epworth Sleep Scale, although neither has been tested for reliability or validity in people with COPD.

CONCLUSION

The results highlight a need for existing non-disease-specific instruments to be validated in COPD populations and also a need for new disease-specific measures to assess the impact of sleep problems in COPD.

Pulmonary rehabilitation and sleep quality: a before and after controlled study of patients with chronic obstructive pulmonary disease

Background:

Poor sleep quality is common in chronic obstructive pulmonary disease (COPD). It is associated with poor quality of life. Pulmonary rehabilitation (PR) improves quality of life, exercise capacity, and anxiety and depression. Its effect on sleep quality is uncertain.

Aim:

To determine whether PR improves sleep quality in COPD.

Methods:

A prospective controlled ‘before and after’ study of sleep quality in COPD patients attending a community PR programme was conducted. Sleep quality was measured using the Pittsburgh Sleep Quality Index (PSQI). Lung function, disease-specific quality of life (COPD assessment test—CAT), exercise capacity (incremental shuttle walk test—ISWT), and anxiety and depression (Hospital Anxiety and Depression Scale—HADS) were measured. Change in sleep quality was compared with a COPD control group.

Results:

Twenty-eight participants completed PR. The control group comprised 24 patients. Prevalence of poor sleep quality (PSQI ⩾5) was 78%. There were no differences between observation and control groups in sleep quality, age or severity. Quality of life was strongly correlated with quality of sleep (r=0.64, P<0.001). PR improved the quality of life (CAT change 3.0; 95% CI, 0.7–5.3), exercise capacity (ISWT change (metres) 81.0; 15.3–146.6), anxiety (HADS score ⩾8: change 2.33; 0.45–4.22), and depression (HADS score ⩾8: change 2.90; 1.92–3.88). PR did not improve sleep quality (PSQI mean change 0.79; −0.35 to 1.93).

Conclusions:

PR did not improve sleep quality in COPD despite improving quality of life, exercise capacity, anxiety and depression. New strategies, independent of PR, are required to improve sleep quality in COPD.

Update on obstructive sleep apnea and its relation to COPD

Chronic obstructive pulmonary disease (COPD) is a common and preventable lung disease that affects millions of people in the United States. Sleep disorders including obstructive sleep apnea (OSA) are also common. It is not surprising that many people with COPD also suffer from OSA. This relationship, however, puts people at risk for more nocturnal desaturations and potential complications related to this, including pulmonary hypertension and heart rhythm disturbances. This update focuses on the physiology of sleep disturbances in COPD as well as the clinical implications of OSA in COPD.