In April 2021, the European Respiratory Society (ERS) held a virtual conference on sleep and breathing disorders. Members of the ELF Sleep Patient Advisory Group (PAG) chose the conference presentations that they were most interested in, and we have prepared lay summaries of those presentations.
Content Table
Dr Simon Herkenrath, University of Cologne Institute of Pulmonology, Germany
In this presentation Dr Herkenrath discussed whether combining more than one treatment for obstructive sleep apnea is better than using a single treatment.
Currently there are several different treatments and therapies for sleep-related breathing disorders. Most patients can find a treatment that works for them. However, some patients do not get enough benefit from using just one treatment. For these patients, a combination of two treatments may be helpful.
A mandibular advancement device (MAD) fits over the teeth and moves the tongue and lower jaw forward. This widens the upper airways and reduces the risk of the airway collapsing. Studies have shown that combining positive airway pressure therapy (PAP) with an MAD helps lower the pressure needed to keep the patient’s upper airway open. This may reduce some of the side effects associated with PAP, such as dry mouth.
Blocking of the upper airway is often worse when a patient is lying on their back. Treatments may not work as well in this position. In this case, combining a treatment with an active sleep position trainer may be useful. For example, it has been shown that an MAD can be more effective if the patient also uses a sleep position trainer.
If patients still experience daytime sleepiness even though their sleep apnea is successfully treated, their treatment can be combined with medication that helps them to remain awake during the day.
Marie Marklund, Umeå University, Sweden
In this presentation Ms Marklund looked at which patients benefit the most from a mandibular advancement device (MAD).
A mandibular advancement device (MAD) fits over the teeth and moves the tongue and lower jaw forward. This widens the upper airways and reduces the risk of the airway collapsing. This can lead to less snoring and lower risk of sleep apnoea. But the device cannot cure the problems in breathing anatomy that might also cause sleep apnoea. Some groups of patients find that MADs do not help very much. Scientists are developing new methods to select patients who are most likely to benefit from MAD therapy.
Research has found that women and patients who are younger or leaner respond best to MAD therapy.. However, the evidence is weak, and MAD might still benefit men and older or larger bodied people. .. Studies have shown that MAD is as effective as continuous positive airway pressure (CPAP) in reducing blood pressure, but most of these studies were done on healthy patients. Other studies have found that CPAP is more effective than MAD at reducing cholesterol and changes in blood pressure. Therefore, CPAP is often advised for patients who are overweight or obese, or at risk from cardiovascular or metabolic disease.
MAD therapy can also improve daytime sleepiness and quality of life. However, there is not much evidence for this, probably because there are many other factors that can influence daytime sleepiness.
A new system has been launched to help decide on the best treatment for Obstructive sleep apnoea (OSA). This is called the Baveno classification. It pays more attention to factors such as daytime sleepiness and the patient’s other health conditions than other methods. Older methods have mainly looked at the number of times a night a person stopped breathing.
MAD is most appropriate for younger and leaner patients who have fewer health conditions. It is important to personalise the approach for each patient. It is likely that many patients in this category are not receiving treatment and would benefit from MAD therapy for their sleep breathing disorder.
Prof. Winfried Randerath, University of Cologne & Bethanien Hospital, Solingen, Germany
In this presentation Prof. Randerath examined the possible links between obesity, sleep apnoea and COVID-19.
People who are very obese are more likely to catch COVID-19. If they catch COVID-19 they are also more likely to need to go into intensive care (ICU) and need help breathing with mechanical ventilation. This is especially likely for people who are less than 60 years old. This could be due to several causes. For example, obesity may make it harder for the lower parts of the lung to inflate, especially when someone is sitting or lying down. This may affect the oxygen level in obese patients. Other possible reasons include high levels of inflammation or swelling, in the body, a higher risk of heart problems and an immune system that doesn’t work as well.
People who are obese are also more likely to have obstructive sleep apnea (OSA). Studies have suggested that having OSA can lead to an increased risk of getting COVID-19 and of dying from it, although the number of patients studied was small. OSA often leads to difficult-to-treat high blood pressure. High blood pressure causes chemical changes in the body. Scientists think this can make it easier for a person to become infected with COVID-19.
People with OSA need to receive effective treatment, this can reduce their risk of becoming seriously ill or dying with COVID-19. Unfortunately, during the pandemic, sleep medicine services were reduced and staff were transferred to other hospital departments. An ERS Task Force has published recommendations on access to sleep laboratories and treatment during the pandemic, for example using telemedicine (such as digital appointments) and adapting tests and treatments to reduce the risk of infection.
Professor Sophia Schiza, Dept of Respiratory Medicine Medical School, University of Crete, Greece
In this presentation Professor Schiza looked at the possible impacts of the COVID-19 pandemic on sleep quality and sleep disorders.
The general public had an increase in anxiety, depression and poor sleep quality during the COVID-19 pandemic. Poor sleep was linked with :
Sleep problems were more common in women, younger unemployed people, and people with financial difficulties caused by lockdown.
Many healthcare workers experienced anxiety, depression and symptoms of insomnia due to long working hours, coping with COVID-19 and its effects on patients and their families, as well as ethical problems with patient needs being greater than the resources they had available.
COVID-19 infection may cause sleep problems in patients in hospital due to the severity of the disease. Sleep problems may also be a symptom of long-COVID. Long-COVID can last for months after getting COVID-19. Symptoms may include:
Long-COVID can be very draining and can affect family life and the person’s ability to work.
There are some studies that show lockdowns due to COVID-19 might have helped some people with sleep. This includes younger people who were able to work from home and avoid commuting, and adolescents who were able to spend more time in bed in the morning.
We need more research and healthcare professionals need to be well trained to recognise and help with the physical and mental health concerns caused by COVID-19 . Managing sleep problems as best as possible can limit stress and have a positive effect on human health and wellbeing.
Prof. Dr. Refika Hamutcu Ersu, Children’s Hospital of Eastern Ontario & University of Ottowa, Canada
In this presentation Prof. Dr. Ersu discussed the effect of the COVID-19 pandemic on children’s sleep.
The COVID-19 pandemic changed normal sleep patterns for children and teenagers. It caused sleep problems in young children and had a negative impact on sleep hygiene – for example, creating a regular sleep schedule, and limiting exposure to light close to bedtime. However, due to home schooling and later starts at school, it was possible for school children to sleep longer in the morning.
Sleep is an important part of healthy living and allows our bodies and brains to rest and recharge. If children and teenagers do not get enough sleep, they can be irritable and develop behavior changes, attention difficulties, and memory problems. Poor sleep also increases the risk of high blood pressure, obesity, depression, and diabetes.
We recommend keeping to regular sleep times for children and practicing good sleep hygiene, such as having a regular routine in the 30 minutes before bedtime that includes calming activities. Using computers, smartphones and watching TV more than usual is likely during the pandemic but we recommend avoiding this after dinner or close to bedtime.
It is particularly important for teenagers to be physically active and eat a good diet. Obesity rates in children increased during the pandemic, due to them being less active and eating high calorie food. Obesity can lead to obstructive sleep apnea (OSA) in children. The closure of many sleep laboratories at the start of the pandemic may have led to delays in the diagnosis of sleep apnea in children, and in starting treatment.
Although the pandemic had a negative effect on sleep for many children, it also created opportunities for change. Increased use of telemedicine and home sleep studies may have helped to limit the negative effect. Using these strategies after the pandemic may also be useful for remote communities.
Lamprou K., Chaidas K., Nickol A. & Stradling J., Oxford University Hospital Sleep and Ventilation Department, Oxford, UK
This presentation outlined the results of a study into reports of sleepiness in patients with obstructive sleep apnoea.
What did the study look at?
The Epworth Sleepiness Scale (ESS) is a questionnaire used to measure the general level of sleepiness in patients with sleep disorders, including obstructive sleep apnoea (OSA). It asks how likely they are to fall asleep in everyday situations. It is possible that some patients with OSA are not aware of how often they fall asleep during the day. Asking a patient’s partner to complete the ESS for the patient might be a more accurate way of assessing daytime sleepiness.
This study looked at whether there was a difference in partner and patient reported sleepiness using the ESS. The test was done both before and after treatment of OSA with continuous positive airway pressure (CPAP). Researchers asked 51 patients with OSA and their partners to complete the ESS before treatment with CPAP, and three months after treatment.
What do the results show?
The results showed no difference in sleepiness score between patient and partner answers. It did not show a link between how severe a patient’s sleep apnoea was, and their sleepiness score before treatment.. There was an improvement in ESS scores three months after treatment.
Why is this important?
It is important to be able to get an accurate measure of patients’ daytime sleepiness. It can be used to assess how well a treatment is working. It can also be used to advise patients on activities that could be affected by sleepiness, such as driving. This study looked at whether a patient’s partner might be able to give a more accurate estimate of daytime sleepiness than the patient themselves. While this study did not find a difference in scores, other studies have shown a difference, and the researchers recommend further research.
It is also important to be able to measure how well a treatment such as CPAP is working. Daytime sleepiness can have a negative effect on a patient’s quality of life, and this study showed that treatment with CPAP can improve daytime sleepiness.
Dr Sean Treanor and Dr Muhammed Asad Khan, Wythenshawe Hospital, Manchester, UK
This presentation outlined a study into whether providing mandibular advancement devices to patients could save money.
What did the study look at?
Obstructive sleep apnea (OSA) is a sleep related disease that causes brief pauses in breathing. This is caused by a collapse of the upper airway. In the UK, continuous positive airway pressure (CPAP) is currently the only universally funded treatment for OSA. Unfortunately, many patients struggle to stick with the CPAP therapy. This can be due to finding the mask or the air pressure uncomfortable, blocked nose and dryness or even claustrophobia (fear of enclosed spaces or of being trapped). Patients can be left with no suitable or effective treatment.
Mandibular advancement devices (MADs) are dental devices which move the lower jaw forward to stop the upper airway collapsing during sleep. MADs can be an effective treatment for all types of OSA.
This study explored whether providing a MAD was a cost-effective option for patients who had struggled with CPAP therapy. It included 148 patients who had attended a specialist sleep centre and been prescribed CPAP. Three months after starting CPAP the patients were asked how often they were using it.
What do the results show?
More than half of the patients were struggling to use CPAP therapy. If these patients had stopped CPAP and instead been fitted with a MAD, there would have been significant cost saving for the service.
Why is this important?
The study shows that offering MAD as an option instead of CPAP could result in cost savings for health authorities. Most importantly, patients who had not been receiving effective treatment for their OSA would have an alternative, effective treatment option.
Gaspar L.S, Hessed J., Yalçind M., Santos B., Carvalhas-Almeida C., Ferreira M., Moitag J., Relógiod A., Cavadasa C., & Álvaro A.R.
This presentation outlined a study that looked into whether treatment for obstructive sleep apnoea can reverse the changes to the body’s biological clock caused by the disease.
What did the study look at?
If not treated, obstructive sleep apnoea (OSA) has been linked with several conditions such as high blood pressure, depression, heart disease and diabetes. Research has tried to find out why OSA can have a negative effect on health. One possible way is that OSA disrupts the body’s biological clock. The biological clock regulates almost all the biological processes of our body throughout the day, and is crucial for health and well-being. Disruptions to the clock may cause or worsen the health conditions and symptoms linked with OSA.
This study looked at whether short-term (4 months) and long-term (2 years) treatment with continuous positive airway pressure (CPAP) affected the biological clock. The researchers checked temperature, hormone levels and the functioning of genes (units of information in your cells) linked with the biological clock.
It included 34 patients with OSA who were using CPAP, and 7 without OSA. Measurements, such as body temperature and blood tests, were taken from all the participants. The 34 patients with OSA also had the same measurements taken 4 months later, and 16 of them had the measurements taken 2 years later.
What do the results show?
The measurements taken from the patients with OSA showed that their biological clock had changed, compared to the participants without OSA. These changes were still there after 4 months of treatment with CPAP. But after 2 years of CPAP treatment, many of the changes had been reversed, although there were still some issues with their biological clock compared to those without OSA.
Why is this important?
The study’s results suggest that the biological clock could be used to diagnose and monitor OSA. The fact that long-term CPAP treatment had more positive effects on the clock of OSA patients shows that CPAP treatment could lessen the risk of other health conditions linked with OSA. On the other hand, the fact that some changes to the biological clock were still there even after long-term treatment suggests that CPAP might not fully fix this issue. This suggests the need for new approaches in OSA diagnosis and treatment. Research to gain a better understanding of the impact of OSA and OSA treatment on the biological clock could lead to new ways to treat and manage OSA.
Fanaridis M., Bouloukaki I., Stathakis G., Steiropoulos P., Mauroudi E., Moniaki V/, Tzanakis N. & Schiza S.
This presentation described a study that looked at the effects of positive airway pressure treatment on patients who had both obstructive sleep apnoea and chronic obstructive pulmonary disease.
What did the study look at?
‘Overlap syndrome’ is the term used when a patient has both obstructive sleep apnoea (OSA) and chronic obstructive pulmonary disease (COPD). Overlap syndrome is linked with poorer health and greater risk of death. This study looked at whether treatment with positive airway pressure (PAP) affected sleepiness, symptoms of depression, need for hospital treatment and death rates in patients with overlap syndrome.
156 patients who had both COPD and moderate to severe OSA were studied over 2 years. The researchers recorded how often the patients used PAP and how many times they had needed to go to hospital. Patients also completed questionnaires such as the Epworth Sleepiness Scale (ESS) to measure how sleepy they were.
What do the results show?
The results showed that those who had used PAP for 6 hours or more each night were less sleepy in the daytime, had fewer hospital stays and symptoms of depression, , and a lower chance of death.
Why is this important?
The results show that using PAP for 6 hours or or more each night is very important to improve survival and symptoms in patients with overlap syndrome.
Prof. Dr. Refika Hamutcu Ersu, Children’s Hospital of Eastern Ontario & University of Ottowa, Canada
In this presentation Prof. Dr. Ersu explained primary snoring in children and outlined the health conditions linked with it.
Primary snoring in children is when snoring happens on more than 3 nights a week, without pauses in breathing (apnoeas), abnormally slow or shallow breathing (hypopneas), frequent waking from sleep, or problems with gas exchange such as the amount of oxygen present in the blood. Primary snoring occurs in children across all ages, and can come and go. Some children with primary snoring will develop obstructive sleep apnoea (OSA). This is more common in children who are obese.
In the past, it was thought that primary snoring did not lead to health problems. But more recent research has suggested that children with primary snoring can have intellectual and behavioural problems similar to children with OSA. Children with primary snoring may also be at increased risk of heart problems and may not produce as much growth hormone as children who do not have primary snoring.
Previous research found no differences in how children with primary snoring moved through the different stages of sleep at night, and how often they woke up, compared to children who have never snored. It is possible that current testing methods may not be sensitive enough to detect subtle changes in children with primary snoring. Other factors such as inflammatory (swelling) response or environmental factors may cause the health effects.
There are no clear treatment guidelines for children with primary snoring. More research is needed to find out which children with primary snoring are more at risk of developing health problems.
Dr An Boudewyns, Antwerp University Hospital & University of Antwerp, Belgium
In this presentation Dr Boudewyns explains the options for surgical treatment of primary snoring in children.
Primary snoring in children is when snoring happens on more than 3 nights a week. Some children with primary snoring can have intellectual or behavioral problems, even though no abnormalities are found during a sleep study. Questionnaires may be helpful to measure symptoms.
For children with primary snoring and poor quality of life, the best option may be to remove the tonsils, the adenoids or both. It is important to consider the risks of surgery, such as pain, bleeding and difficulty eating and drinking for a few days after. However, these risks do not usually outweigh the benefits, such as improved quality of life. Partial tonsil removal surgery may reduce the risk of bleeding and lead to less pain, but there is a higher risk of the primary snoring returning in younger children.
If a child with primary snoring has no problems with health or quality of life then it may be better to ‘wait and see’. This means that there would be no treatment but regular follow-up by a doctor or a non-surgical treatment.
Clinicians should look for other possible causes for primary snoring, such as long-term mouth breathing and a blocked nose, and treat these accordingly. For example, ‘tongue tie’ can lead to mouth breathing and can be treated with surgery.
Some children may have less common snoring sounds such as stridor – a high pitched, creaking sound. If this happens, other causes such as sleep-dependent laryngomalacia, a softening of the voice box, should be looked for. This condition often needs to be operated on.
Milross M.A., Norman M.B. & Sullivan C.E.
This presentation described a study that looked at whether a sleep mat could measure how effective surgery is for sleep disorders in children.
What did the study look at?
The study aimed to assess the effects of surgery to remove the tonsils and adenoids – on sleep disordered breathing in children using a sleep mat. A sleep mat is placed on top of the mattress and records sounds and movement. It records pauses in breathing (apnoeas), abnormally slow or shallow breathing (hypopneas), snoring and stertor (a low pitched breathing noise similar to snoring).
What do the results show?
40 children had a sleep mat, in their own beds, before and after surgery. 34 of the children had a reduction in apnoeas and hypopneas to less than 1 event per hour following surgery. This is usually seen as a “cure”. However, 20 of the 34 still had runs of snoring/stertor. These were associated with body movements, suggesting they had disrupted sleep.
Why is this important?
Although surgery is effective in improving breathing, only measuring the number of apnoeas and hypopneas can over-estimate its success. The study suggests that after surgery, snoring/stertor may still be there at levels that may disrupt sleep. Sleep disruption is linked to behavioural outcomes, so this is an important finding. The results suggest that sleep studies should include measurements of snoring and stertor.
Castro Corrêa C., Fontana Garcia A.L., Padua Ranzani E. & Weber S. Botucatu Medical School, Brazil.
This presentation outlined the results of a study of children who had a tracheostomy.
What did the study look at?
Tracheostomy is the surgical opening of the neck to access the airway (trachea). A tube is inserted to help the patient breathe. The tracheostomy is kept open by a device called a cannula. Decannulation is the process of removing the tracheostomy tube.
This study looked at the records of 64 children who had been in hospital with a tracheostomy between 2015 and 2019, to assess their progress.
What do the results show?
The study showed that many children have a tracheostomy for a long period of time. The average time is 18 months. The process of decannulation can be long and difficult. 25 of the children died, but none of the deaths were because of having a tracheostomy. 10 of the children had a delay in their language development and this was not always tested for early enough.
Why is this important?
The study showed that even in a university hospital with all facilities, children may have a tracheostomy for a long time. These children need support from specialists including speech and language therapists, nutritionists and psychologists, as well as specialist medical follow-up.
Marão A.C., Castro Correa C., Campos L.D. & Weber S.A.T.
This presentation summarised a study looking at whether carrying out a procedure before tonsil removal surgery could predict which children would benefit from the surgery.
What did the study look at?
Breathing problems such as snoring, mouth-breathing and breath pauses are common in children. In some children, these problems are because of obstructive sleep apnoea (OSA). OSA might have negative effects on issues such as blood pressure, heart rate, oxygen saturation (the amount of oxygen in the blood), learning abilities, memory and growth.
In most children, the problems happen because their airway is obstructed by big tonsils, so surgical removal of the tonsils is recommended. However, in some children, breathing problems will continue even after surgery. Currently, we do not have an effective way to decide which children might continue to have problems after surgery.
Sleep endoscopy is an examination with a long thin tube with a camera and light at the end, which is done under general anaesthetic. There is a piece of skin at the back of your tongue that protects your windpipe from food and drink. This is called the epiglottis. If children have a blockage at the base of their tongue or epiglottis, it will not be affected by tonsil surgery. This study did sleep endoscopies in 60 children before tonsil removal surgery to see whether children who had this blockage would continue to have problems after surgery
What do the results show?
Nineteen of the 60 children continued to have breathing problems after surgery, but only 2 of these had shown a blockage at the base of their tongue or epiglottis during the endoscopy.
Why is this important?
The study shows that doing a sleep endoscopy on children before tonsil removal surgery is not a good way to decide which children will benefit from the surgery. Researchers will need to find a better way to measure this so that children with OSA can receive more personalised treatment.
Ucrós S., Granados C., Hill C., Castro-Rodriguez J.A. & Ospina J.C.
This presentation outlined a study looking at whether normal measurements for sleep studies in children can be used in children living at higher altitudes.
What did the study look at?
Obstructive sleep apnoea (OSA) affects between 1 in 100 to 4 in 100 of all children worldwide. OSA in children aged between 3 and 7 is usually caused by enlarged tonsils, adenoids or both. Therefore doctors will often recommend surgery to remove the tonsils, adenoids or both.
The diagnosis of OSA is based on guidelines developed from sleep studies which have been carried out at sea level altitudes. About 140 million people worldwide live at altitudes higher than 2,500m above sea level. The study looked at whether measurements from children at higher altitudes would be different from children living at sea level.
32 healthy, non-snoring children were given a home-based sleep study. The average age of the children was 6 years2 months, and all of them lived at 2,560m above sea level.
What do the results show?
The most important values, such as the number of times per hour the children’s breathing stopped or slowed, were much higher than the normal values given in the current European and American guidelines.
Why is this important?
The results suggest that if guidelines developed from recordings made at sea-level are used with children who live at higher altitudes, it could mean these children get over-diagnosed with OSA. This could lead to unnecessary treatments, including tonsil and adenoid removal surgery. It is important that the guidelines are adjusted for children living at higher altitudes to avoid this happening.
Lo Iacono C.A.M., D’Alessandro C., Amato E. & Carbone I. University of Rome, Italy.
This presentation describes a study that looked at whether there were differences in the characteristics of obstructive sleep apnoea between men and women, and whether aging has an impact.
What did the study look at?
Sleep disturbances in women are often underdiagnosed. This is because some symptoms, such as snoring, are more common in men. It is important to be able to detect other symptoms in women to be able to accurately diagnose conditions such as obstructive sleep apnoea (OSA).
This study analysed the symptoms of OSA using questionnaires and sleep studies. It analysed the symptoms of men and women of different ages to see whether there was a difference.
580 men and 381 women were included in the study. They were divided into two age groups – under and over the age of 65. Researchers studied the participants in their sleep, took measurements such as weight or height, and the participants completed questionnaires including the Epworth Sleepiness Scale (ESS) and Pittsburgh Sleep Quality Index (PSQI).
What do the results show?
The results showed that there were differences both between men and women and between the age groups. For example, OSA was more severe in men, and men snored more. Older women had a higher apnoea-hypopnea index (AHI) – the number of pauses in breathing and periods of shallow breathing – than younger women. In older men and women, having a larger neck size was linked to more severe OSA. Changes in the body that happen with aging, such as increased fat deposits around the throat, could lead to OSA.
The researchers concluded that female patients with OSA are more likely to be older, obese and have different symptoms to male patients. The tests used to diagnose OSA are often not enough to identify the disease in women.
Why is this important?
The results suggest that OSA could be under-diagnosed in women because they have different symptoms to men. If OSA is not treated, this could lead to women being at greater risk of the health problems associated with OSA. Questionnaires tailored to women should be created and used to improve diagnosis.
Prof. Dr. Stijn Verhulst, Antwerp University Hospital, Belgium
In this presentation Dr Verhulst looked at different ways of deciding on the best treatment for children with obstructive sleep apnoea (OSA).
Doctors often advise surgery, such as removal of the tonsils and adenoids, for children with obstructive sleep apnoea (OSA). However, while many children have an improvement in their OSA after such surgery, some do not. OSA may even get worse after surgery. It is important that decisions about treatment for OSA consider the child’s individual circumstances. This will reduce the need for unnecessary surgery and complications after surgery.
It is also important that research looks for ways to find out whether a treatment for OSA in children will be successful before the treatment is carried out. A current way to decide on treatment is by using a drug-induced sleep endoscopy (DISE). DISE is an examination of the upper airway which is carried out under sedation or general anaesthetic before surgery. It can look for abnormalities, blockages and changes in the upper airway that might contribute to OSA. It can also help decide whether surgery could correct the problem. DISE is a safe procedure with no side effects. Studies have suggested that treatment decided using a DICE procedure is more effective than when it is not used.
Alternatives to DISE include imaging techniques such as cine-MRI. Cine-MRI allows us to see movement inside the body. This can be as effective as DISE but it can also be more expensive and usually needs a separate sedation or general anaesthetic.
DISE can be an effective way to guide clinicians to the most appropriate treatment for a child with OSA. Further research is needed to identify other ways of determining the success of treatment.
Professor Sophia Schiza, Dept of Respiratory Medicine Medical School, University of Crete, Greece
In this presentation Prof. Schiza summarised the different sleep disturbances that can occur in patient with chronic obstructive pulmonary disease (COPD).
Almost 8 in 10 patients with chronic obstructive pulmonary disease (COPD) report sleep disturbance. This includes difficulty falling asleep, waking up several times a night and daytime sleepiness. Patients tend to report more sleep disturbances the more severe their COPD is. These patients often do not report their sleep problems to their doctor, or their doctor might not recognise the patient’s sleep disturbances.
Sleep studies carried out with patients with COPD often show poor sleep, such as taking a long time to fall asleep and frequent awakening during the night. People with COPD may have lower oxygen levels, both during the day and at night. This can lead to daytime sleepiness and insomnia. Many people with COPD have insomnia, which is difficulty falling asleep or difficulty staying asleep. As well as low oxygen levels, insomnia can be caused by several other issues such as cough, breathlessness and medication side effects.
Many people with COPD also have anxiety and depression. These can also lead to sleep problems, such as insomnia and daytime sleepiness. It is important for clinicians to assess anxiety and depression in patients with COPD. Treating these problems can improve sleep and daytime symptoms.
Another problem common in people with COPD is restless leg syndrome (RLS). This is an overwhelming urge to move the legs, and most commonly occurs in the evenings and at night. In patients with COPD, RLS can be caused by nicotine use or low levels of the protein ferritin in the blood. Patients who have both COPD and RLS report more symptoms, including daytime sleepiness, taking longer to fall asleep, and poorer quality of life. There is also an association between how severe a patient’s RLS is and their levels of daytime sleepiness and reported quality of sleep.
The term ‘overlap syndrome’ is used when patients have both COPD and obstructive sleep apnoea (OSA). Patients with overlap syndrome have a higher risk of death and of needing to go to hospital. They are also more likely to have COPD exacerbations and reduced quality of life.
All patients with COPD with sleep-related symptoms should be tested for sleep disorders. Treating sleep disorders early can improve health and quality of life, and reduce the risk of going to hospital and of death.
Dr Dries Testelmans, University Hospitals Leuven, Belgium
In this presentation Dr Testelmans discussed treating sleep disorders in patients with COPD using exercise therapy and pulmonary rehabilitation.
Sleep disorders, including sleep apnoea, slow and shallow breathing at night, and insomnia, are common in people with COPD. Patients with COPD should be tested for sleep disorders and receive appropriate treatment.
Physical exercise therapy could be used together with other treatments for sleep problems in older adults, especially since exercise is low cost, widely available and generally safe. Studies have shown that moderate intensity exercise programmes, with a frequency of 3 times per week and a duration of between 12 weeks up to 6 months, have the most positive effect on sleep in older adults.
Pulmonary rehabilitation is a treatment programme for people with lung conditions. It includes a personalised physical exercise programme and advice on managing symptoms. Studies have shown that it can improve symptoms such as breathlessness and tiredness in patients with COPD. It should be offered to all patients with COPD who have relevant symptoms or a high risk of exacerbation (flare-up of their COPD).
The relationship between COPD, sleep and exercise is complex. Different studies show different effects of pulmonary rehabilitation on sleep in patients with COPD. Some patients have an improvement in sleep problems following pulmonary rehabilitation, while others have no change.
Ways to improve sleep should be included when deciding on treatment for COPD. Treating sleep problems could have a positive effect on health and symptoms in people with COPD.
