Chronic obstructive pulmonary disease and obstructive sleep apnea overlap: who to treat and how?

Abstract

Introduction: The co-existence of chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA), or the overlap syndrome, is common and associated with a distinct pattern of nocturnal hypoxemia and worse clinical outcomes than either disease alone. Consequently, identifying who and how to treat these patients is essential.

Areas covered: Treatment is recommended in all patients with OSA and symptoms or systemic hypertension, but determining symptoms attributable to OSA can be challenging in patients with COPD. Treatment should be considered in asymptomatic patients with moderate to severe OSA and COPD with pulmonary hypertension and comorbid cardiovascular and cerebrovascular disease, especially if marked hypoxic burden. CPAP is effective, but in patients with the overlap syndrome and daytime hypercapnia, high-intensity noninvasive ventilation aiming to lower PaCO2 may have additional benefits. Additionally, in those with severe resting daytime hypoxemia, supplemental oxygen improves survival and should be added to positive airway pressure. The role of alternative non-positive airway pressure therapies in the overlap syndrome needs further study.

Expert opinion: Both COPD and OSA are heterogeneous disorders with a wide range of disease severity and further research is needed to better characterize and prognosticate patients with the overlap syndrome to personalize treatment.

Keywords: Overlap syndrome; chronic obstructive pulmonary disease; noninvasive ventilation; obstructive lung disease; obstructive sleep apnea.

Figure 1.

Pathophysiology of overlap syndrome.

Figure 2.

Treatment algorithm COPD-OSA overlap syndrome. *Continuous Positive Airway Pressure; **Cerebrovascular Accident; ***Cardiovascular Disease; ****Noninvasive Ventilation; #BMI ≥ 30 kg/m2 and hypoventilation may be consistent with obesity hypoventilation syndrome; ^Baseline PCO2 ≥ 45 mm Hg; ^^Trial of treatment is reasonable. CPAP preferred first line. Patient preference should be considered in regards to treatment modality. Risk benefits discussions with shared decision making should guide initiation of therapies; ^^^All patients should be counselled regarding risks of drowsy driving.