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					                                                                                    Sleep Waves

                                        Treating Sleep Disorders
                                        in the COPD Patient
                                        Nocturnal hypoxemia,               with SpO2 (saturation measured via pulse
                                        airflow obstruction,               oximetry) levels as low as 37%.3 The most severe
                                                                           desaturations typically occur during REM sleep
                                        fragmented sleep,
                                                                           when most of the skeletal muscles of the body
                                        and insomnia can                   are normally paralyzed with the exception of
                                        affect COPD patients.              muscles of the eyes, diaphragm, and inner ear.
                                                                           In COPD, severe desaturation is related to skele-
                                                                           tal muscle hypotonia and several related factors
                                                                           including hypoventilation, decreased tidal vol-

P
                                                                           ume, reduction in respiratory effort, and blunted
    atients with chronic obstructive pulmonary disease           ventilatory response to hypoxemia and hypercapnia.4-6
(COPD) may be at increased risk for sleep disorders, par-        Patients with higher PaCO2 (arterial carbon dioxide ten-
ticularly persons with moderate to severe COPD. Major            sion) and lower PaO2 (arterial oxygen tension) while
causes of sleep disturbances in this population include gas      awake are more likely to have severe nocturnal desatu-
exchange abnormalities, nocturnal hypoxemia, airflow ob-         ration, although desaturation during sleep may occur in
struction, fragmented sleep, and insomnia. Nocturnal hy-         the absence of daytime desaturation.7 Patients with sig-
poxemia may be triggered by hypoventilation, reduced             nificant nocturnal desaturation may also be at increased
accessory muscle use, decreased functional residual ca-          risk for pulmonary hypertension. Hypoxemia-related in-
pacity, and ventilation perfusion mis-                                             crease in pulmonary vascular resist-
match. Patients with COPD may have                                                 ance may trigger an increase in right
“overlap syndrome,” a co-morbidity of                                              ventricular systolic pressure in an effort
obstructive sleep apnea (OSA) and COPD.                                            to maintain cardiac output. Chronic
Findings commonly associated with OSA                                              hypoxemia in the pulmonary circula-
include daytime sleepiness, impaired                                               tion may result in remodeling of
cognitive function, unrefreshed sleep,                                             the pulmonary vasculature and pul-
snoring, and obesity. Complications of                                             monary hypertension. Increased pul-
OSA may include mood disorders, in-                                                monary vascular resistance and poor
somnia, hypertension, and ischemic                                                 survival have been correlated with se-
heart disease. Patients with COPD may                                              vere nocturnal oxygen desaturation,
experience sleep fragmentation and noc-                                            particularly during REM sleep.8 Noctur-
turnal awakenings triggered by dyspnea,                                            nal oxygen improves both nocturnal
cough, and wheeze. These symptoms                                                  hypoxemia and may improve sleep
and hypoxemia may lead to less overall                                             quality in hypoxemic patients.
                                                    About the Author
total sleep time, more frequent sleep-
                                                Chris Garvey, MSN, MPA, FNP,
stage changes, less rapid-eye movement            AE-C, FAACVPR, is a nurse        COPD and insomnia
(REM) sleep, and impaired quality of life.1   practitioner at the University of        COPD-related symptoms such as
                                               California San Francisco sleep      cough, wheeze, and dyspnea may
Hypoxemia during sleep                           disorders center, as well as      worsen sleep quality. Up to 53% of
   The incidence of OSA in persons               manager of pulmonary and          COPD patients with wheezing report
                                               cardiac rehabilitation at Seton
with COPD mirrors that of the general         Medical Center in Daly City, CA.     symptoms of insomnia, and 23% report
population. Oxygen desaturation and                                                excessive daytime sleepiness.9 In per-
hypoventilation are more common sleep-related abnor-             sons with severe COPD, sleep disturbances are usually as-
malities in persons with COPD than OSA.2 As COPD pro-            sociated with worsening pulmonary mechanics and gas
gresses to moderate to severe levels of impairment,              exchange abnormalities during sleep. These findings may
patients may have significant desaturation during sleep,         lead to increased arousals, frequency of changes in sleep


12   AAR C Ti me s   Nove mb e r 2007
Sleep Waves COPD




stages, and less total sleep time.1 Patients may also ex-survival in those who used oxygen 12–15 hours daily. The
perience insomnia as a side effect of medications in-    survival benefit also paralleled a reduced rate of devel-
cluding systemic corticosteroids and theophylline.       opment of pulmonary hypertension.14 Oxygen may have
                                                         a protective effect by improving nocturnal pulmonary he-
Patient evaluation                                       modynamics in hypoxemic COPD patients.15 In the Med-
   Challenges in diagnosis and management of noctur-     ical Research Council Working Party trial in England,
nal hypoxemia in COPD include the lack of a standard for there was a decrease in five-year mortality and no
evaluation for nocturnal hypoxemia and the difficulty in worsening of pulmonary vascular resistance (PVR) and
predicting nocturnal desatura-                                                     mean pulmonary artery pres-
tion in this population. Pul-                                                      sure (Ppa) in patients treated
monary function has been                   COPD patients should be                 with oxygen.16 Those not
found to have poor correlation              regularly assessed for                 treated with oxygen had an in-
with nocturnal hypoxemia.10                                                        crease in PVR and Ppa. Continu-
The American Thoracic Society            symptoms of sleep apnea,                  ous oxygen was shown to
recommends that patients with              oxygen saturation, and                  improve Ppa and PVR compared
COPD be questioned about                     pulmonary function.                   to nocturnal oxygen in the Noc-
sleep quality and symptoms of                                                      turnal Oxygen Therapy Trial
OSA such as excessive daytime                                                      (NOTT) study.17
sleepiness, snoring, and witnessed apneas. A sleep study    In the NOTT trial, patients receiving continuous oxy-
may be indicated when there is clinical suspicion of OSA gen had a 50% decrease in mortality compared with
because of snoring, witnessed apnea, daytime sleepiness, those on a 12-hour regimen. Sleep-related benefits asso-
unrefreshed sleep, hypertension, obesity, or complica-   ciated with nocturnal oxygen include shorter time
tions of hypoxemia that cannot be explained by awake     needed to fall asleep (or sleep latency), increased REM
arterial oxygen levels.11 Presence of polycythemia, cor  and “deep sleep” Stages 3 and 4, and decreased
pulmonale, and neurocognitive impairment in patients     arousals.18 Management of nocturnal desaturation is not
with COPD with daytime oxygen tension (PO2) greater      always straightforward. Some sources, including Berry
than 60 mm Hg may be an indication for sleep study       and colleagues, recommend that brief periods of mild
for assessment of nocturnal oxygen desaturation and      REM-related desaturation not be treated with supple-
sleep apnea.12                                           mental oxygen.7 Current Medicare coverage guidelines
                                                         for oxygen include:
Treating sleep abnormalities in COPD
   Low flow oxygen may improve nocturnal non-apneic          PaO2 ≤ 55 mm Hg or SaO2 ≤ 88% (awake and at rest)
hypoxemia without significant change in PCO2 (partial                               or
pressure of carbon dioxide). Roger Goldstein and col-                PaO2 = 56–59 mm Hg or SaO2 ≤ 89%
leagues evaluated the effect of supplemental nocturnal                    (awake and at rest) with:
oxygen on blood gases in 15 patients with stable, severe    • Dependent edema suggesting congestive heart
COPD. Use of supplemental oxygen sufficient to keep           failure or
oxygen saturation at or above 90% was associated with       • Pulmonary hypertension or cor pulmonale or
less than 6 mm Hg increase in PCO2 levels during sleep.13   • Erythrocythemia with hematocrit of > 56%.
In some patients, particularly those with hypercapnia,
higher oxygen flow rates may lead to carbon dioxide re-        Potential benefits of nocturnal noninvasive positive
tention with morning headache and confusion. Strate-        pressure ventilation (NIPPV) for patients with COPD re-
gies for minimizing CO2 retention include titrating         main unclear. NIPPV is not recommended as routine
oxygen to maintain the PO2 between 60 and 65 mm Hg.12       treatment for patients with COPD and chronic respira-
   The benefits of continuous oxygen have been well         tory failure. Wijkstra and colleagues published a meta-
documented in the Nocturnal Oxygen Treatment. This          analysis of randomized controlled trials that compared
three-year trial of 203 patients with chronic stable hy-    nocturnal NIPPV with conventional management in pa-
poxemia showed the lowest survival in hypoxemic pa-         tients with COPD and stable respiratory failure. They con-
tients who did not use oxygen and significantly improved    cluded that nocturnal NIPPV in COPD patients without




14   A AR C Tı me s   Nove mb e r 2007
Sleep Waves COPD




OSA does not improve lung function, gas exchange, or       overlap syndrome to treat upper airway obstruction, as
sleep efficiency.19                                        well as enhance gas exchange and reduce work of
   According to the Global Initiative for Chronic Ob-      breathing. Use of supplemental oxygen alone in overlap
structive Lung Disease (GOLD) guidelines, NIPPV and oxy-   syndrome is unlikely to improve impairment and symp-
gen may be appropriate for a selected subset of patients   toms caused by OSA.21 For patients with overlap syn-
such as those with significant daytime hypercapnia.20      drome who have significant hypoxemia despite use of
   Coverage guidelines for NIPPV for severe COPD in-       CPAP or bilevel, supplemental oxygen should be added to
clude the following:                                       CPAP or bilevel. Research such as that by Resta and
                                                           colleagues suggest that patients with overlap of OSA and
• Arterial blood gas with PaCO2 ≥ 52 mm Hg while           COPD tend to tolerate bilevel over CPAP as treatment
  awake on the patient’s usual fraction of inspired        for OSA.22
  oxygen (FIO2)
• Sleep oximetry ≤ 88% for at least five continuous           Current Medicare coverage guidelines for CPAP
  minutes on 2 L/min. of oxygen or the patient’s           include the following:
  usual FIO2 (whichever is higher)
• Prior to treatment, OSA and treatment with con-          1. Facility-based attended sleep study has estab-
  tinuous positive airway pressure (CPAP) has been            lished the diagnosis of OSA including:
  considered and ruled out.                                     a. The apnea-hypopnea index (AHI) is > 15
                                                                   events per hour or
   Continuous positive airway pressure or bilevel posi-         b. The AHI is 5–14 events per hour with docu-
tive airway pressure should be used in patients with               mented excessive daytime sleepiness, im-
                                                                   paired cognition, mood disorders, insomnia,
                                                                   hypertension, ischemic heart disease, or his-
                                                                   tory of stroke.
                                                                c. The recording time for the sleep study must
                                                                   be at least two full hours without treatment.

                                                              Bilevel coverage requires all the above criteria and
                                                           documentation that CPAP has been tried and proven
                                                           ineffective.
                                                              Strategies to promote CPAP or bilevel comfort and ad-
                                                           herence include use of heated humidification and tech-
                                                           nologies that provide pressure relief during exhalation.
                                                           Other strategies for management of OSA include weight
                                                           control as well as avoidance of alcohol and sedatives. Pa-
                                                           tients with daytime sleepiness should be warned against
                                                           driving or operating dangerous equipment.

                                                           Treatment for COPD-related symptoms
                                                           and insomnia
                                                              Nocturnal dyspnea and airflow obstruction may be
                                                           treated with long-acting bronchodilators including long-
                                                           acting anticholinergics, long-acting beta agonists, and
                                                           possibly theophylline. Nebulized ipratropium23 and in-
                                                           haled tiotropium8 have been found to improve nocturnal
                                                           oxygen saturation in patients with COPD.
                                                              Insomnia may be managed with sleep hygiene, cogni-
                                                           tive behavioral therapy, and regular exercise. Sleep hy-
                                                           giene includes a regular schedule for going to bed and
                                                           getting up, avoiding daytime naps and dozing, limiting




16   A AR C Tı me s   Nove mb e r 2007
                                                                                                     Sleep Waves COPD




caffeine and alcohol intake, and avoiding tobacco. The        apnea, assessment of oxygen saturation, and periodic
goal of cognitive behavioral therapy is to help patients      pulmonary function testing. Patients with symptoms
understand the impact that maladaptive thoughts, be-          suggestive of sleep disorders should be evaluated with
haviors, and expectations have on their symptoms and          nocturnal oximetry or polysomnography evaluation. On-
sleep. Examples of maladaptive behaviors and thoughts         going oxygen and/or CPAP or bilevel adherence should be
include watching the clock with each awakening or wor-        monitored and addressed. Adherence may be improved
rying that eight hours of sleep is needed every night for     with regular patient contact, patient education, support
health and well-being. Patients with mood disorders (e.g.,    groups such as AWAKE (Alert, Well, And Keeping Ener-
depression or anxiety disorder) are at greater risk for in-   getic support groups, www.sleepapnea.org/awake/index.
somnia and may benefit from professional counseling           html) and home care support. Identification and maxi-
and pharmacotherapy. Hypnotics should be used with            mal management of comorbidities should be empha-
caution in patients with COPD. Benzodiazepines may im-        sized including congestive heart failure, asthma, and
pair upper airway muscle tone, blunt the respiratory          gastroesophageal reflux disease. The respiratory care
drive, and worsen gas exchange in patients with COPD.12       technician and medical team play a key role in screen-
   Exercise improves function and control of breathless-      ing, clinical evaluation, management, and follow-up of
ness in COPD and improves sleep in many individuals.          persons with COPD and sleep disorders. ■
Pulmonary rehabilitation programs offer monitored and
supervised exercise, along with disease management            REFERENCES
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symptom assessment including symptoms of sleep                                                             (Continued on page 19)




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                                                                                                                 Sleep Waves COPD




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