Download Final, OSAS, ASTHMA - The Egyptian Society of Chest Diseases

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‫وال االخرة اال بعفوه‪...‬‬
‫وال الجنة اال برؤية وجهه الكريم‬
Is There any Link
between OSAS&
ASTHMA?
Dr. Aliaë Abd-Rabou Mohamed-Hussein
European Respiratory Society Scientific Committee
Editor in World Journal of Respirology
Professor of Pulmonology, Chest Department
Assiut University Hospitals, Assiut, Egypt
Size of the problems
6-8% of US population
4-6% of US population
CAN ASTHMA…..
AFFECT SLEEP ???
Patients with asthma appear to
have an increased risk for OSA

Large epidemiologic studies demonstrate that
asthma patients

More frequently report snoring.
 OSA
symptoms are highly prevalent in clinic-based
populations of well-characterized asthma patients.
Also….patients with asthma has
"Nocturnal" awakening
Mechanisms of nocturnal awakening
“asthma”
Probable:
Circadian features
airway inflammation
melatonin
Possible:
Airways cooling
Supine posture
Allergic Factors
Gastroesophageal reflux
Snoring or Sleep Apnea
Sutherland, (2005)
Patients with good control report less frequent and less severe sleep disturbances
compared to uncontrolled subjects.
Conversely,
sleep per se could
…worsen asthma
HOW ????
Normal subject PEFR 8%
Asthmatic subjects 50%

Catterall et al,(1989) found that
 Airway
resistance in asthmatic patients to be
approximately double that in non-asthmatics
at the start of the nocturnal recording period
 and
the magnitude of the overnight rise was
much greater in asthmatics.
Aim: To determine whether a high OSA risk is associated to uncontrolled asthma
Sleep Disorders Questionnaire (SA-SDQ)
Asthma Control Questionnaire. (ACQ)
Multivariate Logistic Regression Models of Not-Well-Controlled Asthma on High OSA Risk,
with Adjustment for Factors Known To Worsen Asthma Control
OSA is a potential contributor to overall asthma control
and indipendent ot the other known contributors to asthma control
OR 3.4
Eur Respir J 2005; 26: 812–818

The National Asthma Education and
Prevention Program Expert Panel Report
recommends evaluating for OSA as a
potential contributor to poor asthma
control.
In short, OSA and Asthma may have a
bidirectional relationship in which each can
exacerbate the other.
What are the links?
Mechanisms linking asthma, and
sleep apnea
CORE
The coexistence and
hypothetical link between

Cough/asthma,

Obesity/OSA,

Rhinosinusitis,
 and Esophageal reflux could be referred to as the
“CORE” syndrome.

In asthmatic patients’ refractory to therapy,
CORE components must be considered in the
management..
1st component
“CORE”
Obesity
Increased incidence of asthma in
overweighed and obese subjects
Beuther DA, Sutherland ER: Overweight, Obesity, and Incident Asthma: A Meta-analysis of Prospective
Epidemiologic Studies. AJRCCM 2007;175:661-666.
Obesity and Asthma
(Mediators)
Beuther DA et al. Pulmonary Perspectives: Obesity and Asthma.
Am J Respir Crit Care Med. 2006;174:112-9
Obesity and OSAS
JOE
The Posthumous Papers of the Pickwick Club- 1836
Charles Dickens
OBESITY IS…….
 Strongest
risk factor for OSA
Present
in > 60% of patients referred for
a diagnostic sleep evaluation
Wisconsin

Sleep Cohort Study
A one standard deviation difference in BMI was
associated with a 4-fold increase in disease
prevalence
OBESITY IS……. A cause of
1- Increased parapharyngeal fat deposition
neck circumference: > 17” males
> 16” females
With subsequent:
 smaller upper airway
 increase the collapsibility of the pharyngeal
airway
OBESITY…….
2. Changes in neural compensatory
mechanisms that maintain airway patency:
 diminished protective reflexes
Obesity………
3. ↑ waist circumference
 ↓functional residual capacity which
can lead to loss of caudal traction on the
upper airway
 low lung volumes are associated
with diminished oxygen stores
2nd component
“CORE”
ASTHMA
OSAS
United Airways Disease
Allergic Rhinitis...
Eosinofphil
IL-5
Basophil
Mast cell degranlulation
Allergen
Challenge
Loss of
Filter ability
Allergen
Post nasal drip
nose-bronchial reflex
Stem cell
Cytokine
Bone marrow
Viral ifection
Eosinophil
ICAM-1
VCAM-1
Allergen bronchial
challenge
Bronchial Asthma
Allergic rhinitis….
 Nasal
obstruction contributes to
snoring, sleep-disordered breathing in
predisposed individuals.
Scharf and Cohen (1997)
rd
3
component
“CORE”
GERD….

GERD is a common condition that affects
approximately 20–30% of the adult population.

Several studies have reported an increased
prevalence of GERD in patients with OSA.
(Spechler, 1992) and (Petersen et al, 1995)
GERD…..

Acid reflux into the airway
enhances Vagal activity
can trigger asthma in some individuals
as well as with symptoms of
OSAS.
Gislason Janson Vermeire et al, (2002)
th
4
component ….”CORE”
(Cardiac)
Sleep Disorders and CV diseases
OSA is associated with significant
cardiovascular morbidities as:
 Left
ventricular dysfunction,
 Arrhythmias,
 Myocardial infarction,
 and Systemic hypertension.
Cardiovascular complications of OSA
and how they may relate to asthma ??
Complication
Resultant effect
Asthma relation
HTN
LVH, IHD, LVD
Pulmonary edema
Asthma worsening
IHD
Ischemia
Asthma worsening
Cough worsening
ASCVD,
HTN
Arrhythmia, Stroke,
decline
cognitive Poor
compliance
medication
PHTN
Dyspnea
Asthma mimic
Medications
Beta–blockers
ACE-inhibitor
Asthma worsening
Cough worsening
with
Adapted from (Kasasbeh et al, 2007)
5th Component ( Inflammation)
A
S
T
H
M
A
O
S
A
S
Multiple Pro-Inflammatory Factors in Allergic
Asthma & Rhinitis Affect Sleep and OSAS
Symptoms
Mediator
Effect on Sleep
Histamine
↑ airway, nasal obstruction, rhinorrhea, & pruritus
Balance between wakefulness and sleep, arousal
CysLT
↑ Nasal, airway obstruction, rhinorrhea
↑ Slow-wave sleep, ↑ Sleep-disordered breathing
IL-1
IL-4
↑ Airway inflammation
↑ Latency to REM and ↓ REM duration
IL-10
Bradykinin
Substance P
↑ Nasal, airway obstruction & rhinorrhea
↑ Sleep apnea;
↑ Latency to REM, arousal; ↑ Nasal obstruction
Adapted from Ferguson. Otolaryngol Head Neck Surg. 2004;130:617.
Treatment modalities
Prospective Clinical Studies Reporting the Impact of Treatment With CPAP
on Asthma Outcome in Patients With Concomitant OSAS
Ann Allergy Asthma Immunol. 2008;101:350–357.
Beneficial effects of CPAP in patients with asthma and
OSAS “LOCAL”
•
↑mean airway pressure
↑ end-expiratory lung volume
•
Recruits underventilated alveoli
↑ expiratory muscle function
• ↑ minute ventilation,
↓ respiratory rate and dyspnea
• ↓ airways resistance
↓ OSAS induce vagal stimulation
•
Stabilizes upper aireways
↓ OSAS induced increased intrathoracic
•
Prevents peripheral airways closure
pressure
Beneficial effects of CPAP in patients with asthma and OSAS
“ SYSTEMIC”
Impact of asthma treatment on
sleep
GERD therapy
OSAS Therapy
GERD
OSAS
Does the treatment of OSA by CPAP
improve GERD?
Author
N
Results
Kerr (1992)
6 OSA
Decreased pH <4 esophageal exposure 6.3–0.1% (p<0.05)
Kerr (1993)
6 non-OSA
Decreased pH <4 esophageal exposure 28–6% (p<0.05)
14 OSA
Decreased pH <4 esophageal exposure 12–4% (p<0.05)
Decreased overall number of reflux events (p<0.05)
8 non-OSA
Decreased pH <4 esophageal exposure 4–1% (p<0.05)
Decreased overall number of reflux events (p<0.05)
165 OSA
48% reduction in GERD symptom score (p<0.001)
While patients without CPAP had no improvement
Ing (2000)
Green (2003)
Does Treatment of GERD (PPI) affect OSA
symptoms?
Author
Ing (2000)
Senior (2001)
Steward (2004)
MohamedHussein et al.,
2011
N
6
10
27
34
Medication (t× time)
Results
Nizatidine (30 days)
50% AI reduction (p<0.05)
No significant reduction in AHI
Symptom reduction not evaluated
Omeprazole (30 days)
31% AI reduction (p=0.04)
25% RDI reduction (p=0.06)
Symptom reduction not evaluated
Pantoprazole (90 days)
No significant reduction in AHI
Reduced daytime sleepiness (p=0.002)
Reduced
GERD
symptoms
(p=0.0006)
Pantoprazole ( 60 days)
Significant reduction in RDI, snoring
events, ESS, improved SaO2
Published articles
Gastroeosophygeal Reflux in Patients with Obstructive Sleep Apnea
Syndrome: Value of isolated treatment with Proton-Pump inhibitor
Aliaë AR Mohamed-Hussein1, M. Kobeisy2, M. Ibrahim3
Chest1, Iinternal Medicine2 and Gastroenterology and Hepatology3 Departments, faculty of Medicine,
Assiut University Hospitals, Assiut, Egypt
Taken together…..

Obstructive sleep apnea (OSA) and asthma can
coexist in the same patient for various reasons.

Obesity

Rhinitis,

GERD
Are common risk factors for both asthma and OSA
and need to be looked for and treated aggressively.

Management of patients with combined
asthma and OSA is often
multidisciplinary, requiring multiple
approaches including:

behavioral/psychosocial,
 pharmacological,
 mechanical (CPAP),
 and surgical therapies.
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‫استغفرك و اتوب اليك‬
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staying awake!
Or, you may now wake
up and ask questions!