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The Disorder

  • "Overlap syndrome” refers to obstructive sleep apnea (OSA) combined with chronic obstructive pulmonary disease (COPD), and has poorer outcomes than either condition alone (1).

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  • OSA-COPD overlap is an important and prevalent condition yet remains under-recognised among the vast majority of respiratory health professionals.

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  • OSA-COPD over- lap has a reported prevalence ranging from 1-10%  due to different methodologies, diagnostic definitions, and demographic characteristics (2). 

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  • The identification and timely treatment of overlap syndrome in patients with COPD therefore can help to improve patient prognosis. 

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  • CPAP is the primary therapy for OSA; however, patients with more advanced COPD, with daytime hypercapnia or severe nocturnal desaturations, may benefit from bilevel-positive airway pressure (1-2).

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  • Patients with overlap syndrome can have greater degrees of night-time oxygen desaturation and cardiovascular consequences than those with either condition in isolation

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  • As well as having overlap syndrome patients with COPD may also have a spectrum of sleep-related breathing disorders, including hypoventilation and central sleep apnea (3)

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1. Bouloukaki I, Fanaridis M, Testelmans D, Pataka A, Schiza S. Overlaps between obstructive sleep apnoea and other respiratory diseases, including COPD, asthma, and interstitial lung disease. Breathe. 2022 Sep 1;18(3).

2.Rajesh S, Wonderling D, Simonds AK. Obstructive sleep apnoea/hypopnoea syndrome and obesity hyperventilation syndrome in over 16s: summary of NICE guidance. BMJ. 2021 Nov 8;375.

3. Suri TM, Suri JC. A review of therapies for the overlap syndrome of obstructive sleep apnea and chronic obstructive pulmonary disease. FASEB BioAdvances. 2021 Sep;3(9):683-93.

 

 

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Consequences

  • Patients with OSA-COPD overlap experience more severe respiratory symptoms and a poorer quality of life,  more daytime sleepiness, and a higher prevalence of hypertension and diabetes than patients with COPD alone

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  •  The relative risk of acute exacerbations, hospitalisations, and mortality is higher than in either disease state alone

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  •  Overlap of these two conditions can also reduce daytime oxygen saturation and increase the frequencies of acute exacerbation, comorbidity, economic burden, and mortality due to COPD (2).

Risk Factors

  • Cigarette smoking is a common risk factor for both COPD and OSA. Smoking can also promote oxidative stress and the release of inflammatory mediators thereby accelerating the underlying pathophysiologic process.

 

  • Obesity is considered the key risk factor for OSA. Neck obesity results in upper airway collapse predisposing individuals to nocturnal oxygen desaturation in patients with overlap syndrome.

 

  • Truncal obesity may reduce chest wall compliance and respiratory muscle strength resulting in ventilatory disturbances and ventilation-perfusion mismatching (4).

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4. Bouloukaki I, Fanaridis M, Testelmans D, Pataka A, Schiza S. Overlaps between obstructive sleep apnoea and other respiratory diseases, including COPD, asthma and interstitial lung disease. Breathe. 2022 Sep 1;18(3).

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Screening and Diagnosis

  • Respiratory polygraphy (either in hospital or at home) is recommended to establish the presence and severity of OSAHS and nocturnal hypoventilation and to help determine the most suitable treatment (such as non-invasive ventilation or CPAP).

 

  • Transcutaneous CO2 monitoring with respiratory polygraphy should also be considered to help confirm nocturnal hypoventilation and the severity of hypercapnia.

 

  • Adding transcutaneous CO2 monitoring with respiratory polygraphy may also help to define the relative contributions of COPD and OSAHS and therefore guide treatment choices and titration of settings.

 

  • The person needs to have stable COPD, without recent exacerbations, before a clear diagnosis can be established (2). 

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Treatment

  • Treatment for COPD- OSA overlap syndrome depends on the level of hypercapnia (arterial blood carbon dioxide level) when awake and asleep. 

 

  • People with more severe hypercapnia when awake are likely to need non-invasive ventilation.

 

  • In these people, a definite benefit of non-invasive ventilation has not been demonstrated when hypercapnia is modest and not associated with exacerbation of COPD). 

 

  • CPAP should be considered in people with COPD–OSAHS overlap syndrome if they have confirmed OSAHS from a sleep study and if their arterial carbon dioxide level is less than or equal to 7.0 kPa

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  • Non-invasive ventilation should be considered if the PaCO2 is higher (2).

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