Top

Published in:

01-12-2020 | Sleep Apnea | Sleep Breathing Physiology and Disorders • Original Article

Overlap syndrome: the coexistence of OSA further impairs cardiorespiratory fitness in COPD

Authors: Luiz Carlos Soares de Carvalho Junior, Renata Trimer, Katiany Lopes Zangrando, Guilherme Peixoto Tinoco Arêas, Flávia Rossi Caruso, José Carlos Bonjorno Junior, Cláudio Ricardo Oliveira, Renata Mendes, Audrey Borghi-Silva

Published in: Sleep and Breathing | Issue 4/2020

Abstract

Background

Cardiorespiratory fitness (CRF) is an important prognostic marker in chronic obstructive pulmonary disease (COPD). Obstructive sleep apnea (OSA) also negatively affects exercise tolerance. However, the impact of their association on CRF has not been evaluated. We hypothesized that patients with overlap syndrome would demonstrate a greater impairment in CRF, particularly those with severe COPD.

Methods

Individuals with COPD were recruited. First, subjects underwent clinical and spirometry evaluation. Next, home-based sleep evaluation was performed. Subjects with an apnea-hypopnea index (AHI) < 15 episodes/h were allocated to the COPD group and those with an AHI ≥ 15 episodes/h to the overlap group. On the second visit, subjects underwent a cardiopulmonary exercise test. Subsequently, they were divided into four groups according to the severity of COPD and coexistence of OSA: COPDI/II; overlap I/II; COPDIII/IV; and overlap III/IV.

Results

: Of the 268 subjects screened, 31 were included. The overlap group exhibited higher values for peak carbon dioxide (COPD: 830 [678–1157]; overlap: 1127 [938–1305] mm Hg; p < 0.05), minute ventilation (COPD: 31 [27–45]; overlap: 48 [37–55] L; p < 0.05), and peak systolic blood pressure (COPD: 180 [169–191]; overlap: 220 [203–227] mm Hg; p <; 0.001) and peak diastolic blood pressure COPD: 100 [93–103]; overlap: 110 [96–106] mm Hg; p < 0.001). COPD severity associated with OSA produced a negative impact on exercise time (COPDIII/IV: 487 ± 102; overlap III/IV: 421 ± 94 s), peak oxygen uptake (COPDIII/IV: 12 ± 2; overlap III/IV: 9 ± 1 ml.Kg.min⁻¹ ; p < 0.05) and circulatory power (COPDIII/IV: 2306 ± 439; overlap III/IV: 2162 ± 340 ml/kg/min.mmHg; p < 0.05).

Conclusion

Overlap syndrome causes greater hemodynamic and ventilatory demand at the peak of dynamic exercise. In addition, OSA overlap in individuals with more severe COPD impairs CRF.

GOLD. Global initiative for chronic obstructive. Global Obstructive Lung Disease. 2018:http://www.goldcopd.org. doi:https://doi.org/10.1097/00008483-200207000-00004. Accessed 7 July 2018

Kim V, Crapo J, Zhao H et al (2015) Comparison between an alternative and the classic definition of chronic bronchitis in COPDGene. Anna Am Thor Soc. https://doi.org/10.1513/AnnalsATS.201411-518OC

Lozano R, Naghavi M, Foreman K et al (2012) Global and regional mortality from 235 causes of death for 20 age groups in 1990 and 2010: a systematic analysis for the global burden of disease study 2010. Lancet. https://doi.org/10.1016/S0140-6736(12)61728-0

Chen W, Thomas J, Sadatsafavi M, FitzGerald JM (2015) Risk of cardiovascular comorbidity in patients with chronic obstructive pulmonary disease: a systematic review and meta-analysis. Lancet Respir Med. https://doi.org/10.1016/S2213-2600(15)00241-6

Mannino DM, Higuchi K, Yu TC et al (2015) Economic burden of COPD in the presence of comorbidities. Chest. https://doi.org/10.1378/chest.14-2434

Laukkanen JA, Kurl S, Salonen R, Rauramaa R, Salonen JT (2004) The predictive value of cardiorespiratory fitness for cardiovascular events in men with various risk profiles: a prospective population-based cohort study. Eur Heart J. https://doi.org/10.1016/j.ehj.2004.06.013

Palange P, Ward SA, Carlsen K-H et al (2007) Recommendations on the use of exercise testing in clinical practice. Eur Respir J 29(1):185–209. https://doi.org/10.1183/09031936.00046906CrossRefPubMed

Ferrazza AM, Martolini D, Valli G, Palange P (2009) Cardiopulmonary exercise testing in the functional and prognostic evaluation of patients with pulmonary diseases. Respiration. https://doi.org/10.1159/000186694

Waschki B, Kirsten AM, Holz O et al (2015:in pres) Disease progression and changes in physical activity in patients with COPD. Am J Respir Crit Care Med. https://doi.org/10.1164/rccm.201501-0081OC

10.

Guenette JA, Chin RC, Cheng S et al (2014) Mechanisms of exercise intolerance in global initiative for chronic obstructive lung disease grade 1 COPD. Eur Respir J 44(5):1177–1187. https://doi.org/10.1183/09031936.00034714CrossRefPubMed

11.

Mendelson M, Marillier M, Bailly S et al (2018) Maximal exercise capacity in patients with obstructive sleep apnoea syndrome: a systematic review and meta-analysis. Eur Respir J. https://doi.org/10.1183/13993003.02697-2017

12.

Savonen KP, Lakka TA, Laukkanen JA, Halonen PM, Rauramaa TH, Salonen JT, Rauramaa R (2006) Heart rate response during exercise test and cardiovascular mortality in middle-aged men. Eur Heart J 27(5):582–588. https://doi.org/10.1093/eurheartj/ehi708CrossRefPubMed

13.

Przybyłowski T, Bielicki P, Kumor M et al (2007) Exercise capacity in patients with obstructive sleep apnea syndrome. J Physiol Pharm : an official journal of the Polish Physiological Society 58(Suppl 5(Pt 2)):563–574

14.

Guilleminault C, Cummiskey J, Motta J (1980) Chronic obstructive airflow disease and sleep studies. Am Rev Respir Dis 122(3):397–406PubMed

15.

Chaouat ARI, Weitzenblum E, Krieger J, Ifoundza T, Oswald M, Kessler R (1995) Association of chronic obstructive pulmonary disease and sleep apnea syndrome. Am J Respir Crit Care Med 151(1):82–86CrossRef

16.

Torres-Palacios A, Elena Ocasio-Tascón M, Campos-Santiago Z, Rodríguez-Cintrón W (2009) Syndrome: an indication for sleep studies?: a pilot study. Sleep Breath 13(4):409–413CrossRef

17.

Sanders MH, Newman AB, Haggerty CL, Redline S, Lebowitz M, Samet J, O'Connor GT, Punjabi NM, Shahar E, Sleep Heart Health Study (2003) Sleep and sleep-disordered breathing in adults with predominantly mild obstructive airway disease. Am J Respir Crit Care Med 167(1):7–14. https://doi.org/10.1164/rccm.2203046CrossRefPubMed

18.

Celli BR, MacNee W, Agusti A et al (2004) Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J 23(6):932–946. https://doi.org/10.1183/09031936.04.00014304CrossRefPubMed

19.

da Silva GPF, Morano MTAP, Viana CMS, de Araujo Magalhães CB, Pereira EDB (2013) Validação do Teste de Avaliação da DPOC em português para uso no Brasil. J Bras Pneumol 39(4):402–408. https://doi.org/10.1590/S0104-42302003000300025CrossRefPubMedPubMedCentral

20.

Jones PW, Harding G, Berry P, Wiklund I, Chen WH, Kline LN (2009) Development and first validation of the COPD assessment test. Eur Respir J 34(3):648–654. https://doi.org/10.1183/09031936.00102509CrossRefPubMed

21.

Celli BR, Cote CG, Marin JM et al (2004) The body-mass index, airflow obstruction, dyspnea, and exercise capacity index in chronic obstructive pulmonary disease. N Engl J Med. https://doi.org/10.1056/NEJMoa021322

22.

Miller MR, Hankinson J, Brusasco V, Burgos F, Casaburi R, Coates A, Crapo R, Enright P, van der Grinten C, Gustafsson P, Jensen R, Johnson DC, MacIntyre N, McKay R, Navajas D, Pedersen OF, Pellegrino R, Viegi G, Wanger J, ATS/ERS Task Force (2005) Standardisation of spirometry. Eur Respir J 26(2):319–338. https://doi.org/10.1183/09031936.05.00034805CrossRefPubMed

23.

Alberto de Castro Pereira C, Sato T, Carla Rodrigues S (2007) Novos valores de referência para espirometria forçada em brasileiros adultos de raça branca* New reference values for forced spirometry in white adults in Brazil. J Bras Pneumol 33(4):397–406. https://doi.org/10.1590/S1806-37132007000400008CrossRef

24.

Epstein LJ, Kristo D, Strollo PJ, et al. (2009) Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med : JCSM : official publication of the American Academy of Sleep Medicine

25.

Berry RB, Budhiraja R, Gottlieb DJ et al (2012) Rules for scoring respiratory events in sleep: update of the 2007 AASM manual for the scoring of sleep and associated events. J Clin Sleep Med. https://doi.org/10.5664/jcsm.2172

26.

Fletcher GF, Ades PA, Kligfield P et al (2013) Exercise standards for testing and training: A scientific statement from the American heart association. Circulation. https://doi.org/10.1161/CIR.0b013e31829b5b44

27.

Gibbons RJ, Balady GJ, Bricker JT, Chaitman BR, Fletcher GF, Froelicher VF, Mark DB, McCallister B, Mooss AN, O'Reilly MG, Winters WL Jr, Gibbons RJ, Antman EM, Alpert JS, Faxon DP, Fuster V, Gregoratos G, Hiratzka LF, Jacobs AK, Russell RO, Smith SC Jr, American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1997 Exercise Testing Guidelines) (2002) ACC/AHA 2002 guideline update for exercise testing: summary article. A report of the American College of Cardiology/American Heart Association task force on practice guidelines (committee to update the 1997 exercise testing guidelines). Circulation. 106(14):1883–1892. https://doi.org/10.1161/01.CIR.0000034670.06526.15CrossRefPubMed

28.

Baba R (2000) The oxygen uptake efficiency slope and its value in the assessment of cardiorespiratory functional reserve. Congestive Heart Failure (Greenwich, Conn). https://doi.org/10.1111/j.1527-5299.2000.80164.x

29.

Neder JA, Arbex FF, Alencar MCN et al (2015) Exercise ventilatory inefficiency in mild to end-stage COPD. Eur Respir J. https://doi.org/10.1183/09031936.00135514

30.

Poon CS, Tin C, Song G (2015) Submissive hypercapnia: why COPD patients are more prone to CO2 retention than heart failure patients. Respir Physiol Neurobiol. https://doi.org/10.1016/j.resp.2015.03.001

31.

Forman DE, Guazzi M, Myers J et al (2012) Ventilatory power: a novel index that enhances prognostic assessment of patients with heart failure. Circ Heart Fail. https://doi.org/10.1161/CIRCHEARTFAILURE.112.968529

32.

Williams SG, Tzeng BH, Barker D, Tan LB (2005) Comparison and relation of indirect and direct dynamic indexes of cardiac pumping capacity in chronic heart failure. Am J Cardiol. https://doi.org/10.1016/j.amjcard.2005.06.051

33.

Barron A, Francis DP, Mayet J et al (2016) Oxygen uptake efficiency slope and breathing reserve, not anaerobic threshold, discriminate between patients with cardiovascular disease over chronic obstructive pulmonary disease. JACC: Heart Failure 4(4):252–261. https://doi.org/10.1016/j.jchf.2015.11.003CrossRefPubMed

34.

Robles P, Araujo T, Brooks D, Zabjek K, Janaudis-Ferreira T, Marzolini S, Goldstein R, Mathur S (2017) Cardiorespiratory responses to short bouts of resistance training exercises in individuals with chronic obstructive pulmonary disease. J Cardiopulm Rehab Prev 37(5):356–362. https://doi.org/10.1097/HCR.0000000000000282CrossRef

35.

Skjørten I, Hilde JM, Melsom MN (2018) Cardiopulmonary exercise test and PaO 2 in evaluation of pulmonary hypertension in COPD. Int J COPD:91–100

36.

Hargens TA, Guill SG, Aron A, Zedalis D, Gregg JM, Nickols-Richardson SM, Herbert WG (2009) Altered ventilatory responses to exercise testing in young adult men with obstructive sleep apnea. Respir Med 103(7):1063–1069. https://doi.org/10.1016/j.rmed.2009.01.010CrossRefPubMed

37.

Aron A, Zedalis D, Gregg JM, Gwazdauskas FC, Herbert WG (2009) Potential clinical use of cardiopulmonary exercise testing in obstructive sleep apnea hypopnea syndrome. Int J Cardiol 132(2):176–186. https://doi.org/10.1016/j.ijcard.2008.11.014CrossRefPubMed

38.

Oliveira MF, Arbex F, Alencar MC, et al. (2016) Heart Failure Impairs Muscle Blood Flow and Endurance Exercise Tolerance in COPD. Copd. doi:https://doi.org/10.3109/15412555.2015.1117435

39.

Meguro K, Adachi H, Oshima S, Taniguchi K, Nagai R (2005) Exercise tolerance, exercise hyperpnea and central chemosensitivity to carbon dioxide in sleep apnea syndrome in heart failure patients. Circulation Journal : Official Journal of the Japanese Circulation Society. https://doi.org/10.1253/circj.69.695

40.

Arzt M, Harth M, Luchner A et al (2003) Enhanced ventilatory response to exercise in patients with chronic heart failure and central sleep apnea. Circulation. https://doi.org/10.1161/01.CIR.0000065227.04025.C2

41.

Teopompi E, Tzani P, Aiello M et al (2014) Ventilatory response to carbon dioxide output in subjects with congestive heart failure and in patients with COPD with comparable exercise capacity. Respir Care. https://doi.org/10.4187/respcare.02629

42.

Apostolo A, Laveneziana P, Palange P et al (2015) Impact of chronic obstructive pulmonary disease on exercise ventilatory efficiency in heart failure. Int J Cardiol. https://doi.org/10.1016/j.ijcard.2015.03.422

43.

Malhotra A, Loscalzo J (2008) Sleep and cardiovascular disease. Sleep Cardiovasc Dis 52(8):686–717

44.

Fletcher EC, Bao G, Miller CC (1995) Effect of recurrent episodic hypocapnic, eucapnic, and hypercapnic hypoxia on systemic blood pressure. J Appl Physiol. https://doi.org/10.1152/jappl.1995.78.4.1516

45.

Tarasiuk A, Scharf SM, Belmonte A (1994) Cardiovascular effects of periodic obstructive and central apneas in dogs. Am J Respir Crit Care Med. https://doi.org/10.1164/ajrccm.150.1.8025778

46.

Sapru HN (1996) Carotid chemoreflex. Neural pathways and transmitters. Adv Exp Med Biol

47.

Narkiewicz K, van de Borne PJ, Pesek CA, Dyken ME, Montano N, Somers VK. Selective potentiation of peripheral chemoreflex sensitivity in obstructive sleep apnea. 99:1183-1189; 1999. doi:https://doi.org/10.1161/01.CIR.99.9.1183

48.

Taranto-Montemurro L, Messineo L, Perger E et al (2016) Cardiac sympathetic hyperactivity in patients with chronic obstructive pulmonary disease and obstructive sleep apnea. COPD: J Chron Obstruct Pulmon Dis. https://doi.org/10.1080/15412555.2016.1199668

49.

Zangrando KTL, Trimer R, de Carvalho LCS et al (2018) Chronic obstructive pulmonary disease severity and its association with obstructive sleep apnea syndrome: impact on cardiac autonomic modulation and functional capacity. Int J COPD. https://doi.org/10.2147/COPD.S156168

50.

Dempsey JA, Romer L, Rodman J, Miller J, Smith C (2006) Consequences of exercise-induced respiratory muscle work. Respir Physiol Neurobiol 151(2–3):242–250. https://doi.org/10.1016/j.resp.2005.12.015CrossRefPubMed

51.

Clarenbach CF, Senn O, Sievi NA et al (2013) Determinants of endothelial function in patients with COPD. Eur Respir J. https://doi.org/10.1183/09031936.00144612, https://doi.org/10.1183/09031936.00144612

52.

Cohen-Solal A, Tabet JY, Logeart D, Bourgoin P, Tokmakova M, Dahan M (2002) A non-invasively determined surrogate of cardiac power ('circulatory power’) at peak exercise is a powerful prognostic factor in chronic heart failure. Eur Heart J. https://doi.org/10.1053/euhj.2001.2966

53.

Marrara KT, Di Lorenzo VAP, Jaenisch RB et al (2018) Noninvasive ventilation as an important adjunct to an exercise training program in subjects with moderate to severe COPD. Respir Care 63(11):1388–1398. respcare.05763. https://doi.org/10.4187/respcare.05763CrossRefPubMed

54.

Guazzi M, Adams V, Conraads V et al (2012) Clinical recommendations for cardiopulmonary exercise testing data assessment in specific patient populations. Circulation. https://doi.org/10.1161/CIR.0b013e31826fb946

55.

Guazzi M, Arena R, Halle M, Piepoli MF, Myers J, Lavie CJ (2016) 2016 focused update: clinical recommendations for cardiopulmonary exercise testing data assessment in specific patient populations. Circulation. https://doi.org/10.1161/CIR.0000000000000406

56.

Marin JM, Soriano JB, Carrizo SJ, Boldova A, Celli BR (2010) Outcomes in patients with chronic obstructive sleep apnea: the overlap syndrome. Am J Respir Crit Care Med. https://doi.org/10.1164/rccm.200912-1869OC

Title: Overlap syndrome: the coexistence of OSA further impairs cardiorespiratory fitness in COPD
Authors: Luiz Carlos Soares de Carvalho Junior
Renata Trimer
Katiany Lopes Zangrando
Guilherme Peixoto Tinoco Arêas
Flávia Rossi Caruso
José Carlos Bonjorno Junior
Cláudio Ricardo Oliveira
Renata Mendes
Audrey Borghi-Silva
Publication date: 01-12-2020
Publisher: Springer International Publishing
Keywords: Sleep Apnea
Chronic Obstructive Lung Disease
Mixed Connective Tissue Disease
Published in: Sleep and Breathing / Issue 4/2020
Print ISSN: 1520-9512
Electronic ISSN: 1522-1709
DOI: https://doi.org/10.1007/s11325-019-02002-2

ACC 2024 Congress Coverage

Cardiology Video

Highlights from the ACC 2024 Congress

Watch now

Watch official videos from the ACC congress summarizing key highlights from the last year in heart failure, cardiomyopathies, valvular disease, pulmonary vascular disease, and pediatric cardiology.

Semaglutide benefits people with type 2 diabetes and obesity-related heart failure

16-04-2024 Type 2 Diabetes News

Incentivised to exercise

11-04-2024 Lifestyle Modifications News

New intervention for STEMI-related cardiogenic shock

10-04-2024 Myocardial Infarction News

» View more highlights on the ACC 2024 congress hub page

Image Credits

ACC 2024 Pediatric and Congenital Heart Disease: Year in Review/© 2024 American College of Cardiology, ACC 2024 Pulmonary Vascular Disease: Year in Review/© 2024 American College of Cardiology, ACC 2024 Valvular Heart Disease: Year in Review/© 2024 American College of Cardiology, ACC 2024 HF and Cardiomyopathies: Year in Review/© 2024 American College of Cardiology, Woman out walking/© Seventyfour / stock.adobe.com (symbolic image with model), Woman checking smartwatch /© saltdium / stock.adobe.com (symbolic image with model), Cardiac catheterization/© Damian / stock.adobe.com

ACC 2024 Congress

Springer Medicine

Abstract

Background

Methods

Results

Conclusion

Please log in to get access to this content

Other articles of this Issue 4/2020

Evening sock marks as an adjunct to the clinical prediction of obstructive sleep apnea

A review of the association between oral bacterial flora and obstructive sleep apnea–hypopnea syndrome comorbid with cardiovascular disease

Refining screening questionnaires for prediction of sleep apnea severity in children

Impact of severe OSA on pharmacoinvasive treatment in ST elevation myocardial infarction patients