Sleep and COPD

1
Sleep and COPD
Barbara Phillips, MD, MSPH, FCCP
Sleep Academic Award
1
2
Palliative Care Sleep and COPD
Sleep Academic Award
2
3
Sleep and Breathing(what Im going to tell you)

• Effects of aging on sleep
• Effects of sleep on breathing and COPD
• Effects of COPD on sleep
• Associated sleep disorders (OSA and RLS)
• Approaches to treating all of the above

Sleep Academic Award
3
4
Sleep Changes With Age

• Increased awakenings and arousals
• Decreased REM sleep
• Decreased SWS
• Increased stage shifts
• Fewer cycles
• Reduced sleep efficiency
• Phase advancement

5
Sleep Complaints in the Elderly

• Women complain more than men but sleep better
• Poor sleep correlates with poor health
• Poor sleep correlates with depression
• Daytime napping is associated with increased
  mortality
• Over half of elderly have a sleep complaint (DIMS)

6
Effects of Sleep on Breathing (with or without
COPD)

• Decreased ventilatory drive
• Increased airway resistance
• Pooling of secretions
• Muscle atony in REM sleep
• Reduced FRC increased V / Q mismatch
• Bottom line hypoxemia during sleep

Sleep Academic Award
6
7
COPD Patients Sleep Poorly

• EEG sleep changes in COPD patients
• long sleep latency and WASO
• reduced sleep efficiency and total sleep time
• Poor sleep in COPD is multifactorial
• drugs
• depression
• sedentary lifestyle / poor sleep hygiene
• hypoxemia
• cough
• aging

Sleep Academic Award
7
8
Effects of Sleep Disturbance

• Impaired mood
• Impaired vigilance
• Impaired memory
• Increased upper airway collapsibility
• Decreased respiratory drive
• Worsened sleep apnea

9
COPD and OSAThe Overlap Syndrome

• OSA and COPD are both prevalent
• (3 / 31 and 15 respectively)
• OSA and COPD share risk factors
• male gender, age, cigarette smoking
• Control of breathing defect may predispose to
  OSA
• 11 of 265 patients with OSA have COPD
• 20-40 of patients with COPD have OSA

Sleep Academic Award
9
10
Clinically Important OSA Peaks in Mid-life

• Survivorship?
• Obesity peaks in middle age
• CSA doesnt count

11
What is Sleep Apnea in the Elderly??

• 1/3 of seniors have AHI gt 5
• AI gt 20 does not predict mortality in aged
• Morbidity and mortality increase with increasing
  AHI

12
Restless Legs Syndrome (RLS)

• Uncomfortable leg sensations (that are)
• Worse at night (and)
• Worse with inactivity but relieved by activity
  (and are associated with)
• Motor hyperactivity

Sleep Academic Award
12
13
RLS and COPD Patients

• Overall prevalence is 10 -15
• Prevalence increases with age
• Prevalence in a VA population 21
• Risk factors
• Cigarette smoking
• Medications (theophylline, tricyclics, SSRIs)

Sleep Academic Award
13
14
Treatment for COPD / Sleep Disturbance

• The basics
• OXYGEN!!
• Medications
• Non-invasive ventilatory support
• Hypnotics

Sleep Academic Award
14
15
Treatment of Sleep Disturbance in the
Elderly-Basic Stuff

• Regular schedule
• Nocturnal activities hour (2-4 am)
• NO NAPPING!!!!!
• Bright outdoor sunlight
• Exercise!
• No smoking!!!
• Melatonin?

16
Oxygen

• 15 to 24 hours / day can reduce mortality in COPD
  (and 24 hours is better than 12)
• Nocturnal oxygen
• Probably improves sleep quality
• Can make apneas longer
• Isolated sleep hypoxemia (Sa02 lt 85) is
  associated with increased mortality
• Oxygen reduces PA pressure in this group
• Oxygen may not affect mortality in this group

Sleep Academic Award
16
17
Pharmacologic Treatment

• Protriptyline
• improves Sa02 / depresses REM and urine flow
• Almitrine / progesterone
• can improve Sa02, but side effects limit use
• Theophylline
• improves Sa02 / variable effects on sleep

Sleep Academic Award
17
18
Pharmacologic Treatment (cont.)

• Beta agonists
• do not improve Sa02 / adverse effects on sleep
• Ipratropium Bromide
• improves sleep quality and Sa02

19
Noninvasive Ventilatory Support

• Negative-pressure ventilation
• poorly tolerated, worsens OSA
• Bi-level positive airway pressure
• improves Sa02 and sleep
• Bi-level positive airway pressure plus 02
• improves Sa02 and sleep (better than 02)
• Continuous positive airway pressure
• useful for overlap

Sleep Academic Award
19
20
ACCP Consensus Conference on NPPV in COPD

• Symptoms (fatigue, dyspnea, headache)
• AND
• PaCO2 gt 55 mmHg
• OR
• PaCO2 50-54 mmHg with SaO2 lt 88 for 5 minutes
  while on 2 l/min
• OR
• PaCO2 50-54 and recurrent hospitalization for
  hypercapneic respiratory failure

Sleep Academic Award
20
21
Hypnotics

• Concerns about BDZ hypnotics
• dependence
• respiratory depression

Sleep Academic Award
21
22
The Ugly Truth

• BDZ use among independent seniors ( gt 65y)
• 12 for women 9 for men
• BDZ use among sick VA patients
• 17
• BDZ use among institutionalized patients
• 34

Sleep Academic Award
22
23
Consequences of BDZ Use in the Cardiovascular
Health Study

• Less daytime sleepiness in women

Sleep Academic Award
23
24
Treatment of Insomnia 1999(Walsh et al)

• Pharmacologic Rx of insomnia is decreasing
• Trazadone is the 1 hypnotic used to Rx insomnia
• Compared with zolpidem, trazadone is
• more toxic
• less effective

Sleep Academic Award
24
25
Hypnotics

• Many patients with COPD sleep poorly for
  irreversible reasons
• Newer hypnotics do not cause significant
  respiratory depression, and are probably
  underused in end-stage COPD patients

Sleep Academic Award
25
26
Conclusions (what I told you)

• Sleep disturbances and disorders are common in
  patients with COPD
• Treatable sleep problems in COPD patients
• Hypoxemia
• OSA
• RLS
• Insomnia
• We miss opportunities to help these patients when
  we dont ask about, evaluate, or treat sleep
  problems

Sleep Academic Award
26