سبحان من لا تطيب الدنيا الا بذكره ... ولا الاخرة الا...
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سبحان من ال تطيب الدنيا اال سبحان من ال تطيب الدنيا اال بذكره ...بذكره ...
وال االخرة اال بعفوه... وال االخرة اال بعفوه...وال الجنة اال برؤية وال الجنة اال برؤية
وجهه الكريموجهه الكريم
Is There any Link Is There any Link between between OSAS& OSAS&
ASTHMAASTHMA??
Dr. Aliaë Abd-Rabou Mohamed-HusseinEuropean Respiratory Society Scientific European Respiratory Society Scientific CommitteeCommittee
Editor in World Journal of RespirologyEditor in World Journal of RespirologyProfessor 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…..CAN ASTHMA…..
AFFECT AFFECT SLEEP ???SLEEP ???
Patients with Patients with asthmaasthma appear to appear to have an increased risk for have an increased risk for OSAOSA
Large epidemiologic studies demonstrate that asthma patients
More frequently report snoringsnoring.
OSA symptomsOSA symptoms are highly prevalent in clinic-based populations of well-characterized asthma patients.
Also….patients with Also….patients with asthma asthma has has "Nocturnal""Nocturnal" awakening awakening
Mechanisms of nocturnalnocturnal awakening “asthma”asthma”
Probable:Probable:Circadian features
airway inflammationmelatonin
Possible:Possible:Airways coolingSupine postureAllergic FactorsGastroesophageal refluxSnoring or Sleep Apnea
Sutherland, (2005)
Patients with good controlgood control report less frequent and less severe sleep disturbancesless frequent and less severe sleep disturbancescompared to uncontrolled subjects.
Conversely, Conversely, sleepsleep per se could per se could
…worsen …worsen asthmaasthma
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 overnightovernight riserise 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,High OSA Risk, with Adjustment for Factors Known To Worsen Asthma Control
OSAOSA is a potential contributor to overall asthma controlasthma 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 OSA as a potential contributor to poor asthma poor asthma controlcontrol.
In short, OSAOSA and AsthmaAsthma may have a bidirectional relationship in which each can
exacerbate the other .
What are the linksWhat are the links??
Mechanisms linking asthma, and Mechanisms linking asthma, and sleep apneasleep apnea
CORECORE
The coexistence and The coexistence and hypothetical link betweenhypothetical link between
Cough/asthma, Obesity/OSA,
Rhinosinusitis, and Esophageal reflux could be referred to as the
““CORE”CORE” syndrome.
In asthmatic patients’ refractory to therapy, CORE CORE components must be considered in the management..
1st component “COORE”
ObesityObesity
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.
Beuther DA et al. Pulmonary Perspectives: Obesity and Asthma. Am J Respir Crit Care Med. 2006;174:112-9
Obesity and Asthma(Mediators)
ObesityObesity and OSASOSASThe Posthumous Papers of the Pickwick Club- 1836
Charles Dickens
JOE
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 ISOBESITY 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
OBESITYOBESITY.……
2. Changes in neural compensatory mechanisms that maintain airway patency:
diminished protective reflexes
ObesityObesity ……… ………
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 “CORRE”
ASTHMAASTHMA
OSASOSAS
Bronchial Asthma
Allergen bronchial challenge
EosinofphilIL-5
BasophilMast cell degranlulation
EosinophilICAM-1VCAM-1
Allergen Challenge
nose-bronchial reflex
Allergen
Post nasal drip
Cytokine
Loss ofFilter ability
Viral ifection
Bone marrow
Stem cell
Allergic Rhinitis...
United Airways Disease
Allergic rhinitisAllergic rhinitis .…
Nasal obstruction contributes to snoring, sleep-disordered breathing in predisposed individuals.
Scharf and Cohen (1997)
3rd component “COREE”
GERDGERD.….…
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)
GERDGERD..…..…
Acid reflux into the airway
enhances Vagal activity
can trigger asthma asthma in some individuals
as well as with symptoms of
OSASOSAS. Gislason Janson Vermeire et al, )2002(
4th component ….”CCORE”(Cardiac)
Sleep Disorders and CV diseases
OSA is associated with significant cardiovascular morbidities as:
Left ventricular dysfunction, Arrhythmias, Myocardial infarction, and Systemic hypertension.
CardiovascularCardiovascular complications of OSAOSA and how they may relate to asthma asthma??
ComplicationResultant effectAsthma relation
HTNLVH, IHD, LVDPulmonary edemaAsthma worsening
IHDIschemiaAsthma worseningCough worsening
ASCVD, Arrhythmia, HTN
Stroke, cognitive decline
Poor compliance with medication
PHTNDyspneaAsthma mimic
MedicationsBeta–blockersACE-inhibitor
Asthma worseningCough worsening
Adapted from (Kasasbeh et al, 2007)
5th Component ( Inflammation)
A
S
T
H
M
A
OSAS
Multiple Pro-Inflammatory Factors in Allergic Asthma & Rhinitis Affect Sleep and OSAS Symptoms
MediatorEffect 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↑ Airway inflammation
↑ Latency to REM and ↓ REM durationIL-4
IL-10
Bradykinin↑ Nasal, airway obstruction & rhinorrhea
↑ Sleep apnea;
Substance P↑ Latency to REM, arousal; ↑ Nasal obstructionAdapted from Ferguson. Otolaryngol Head Neck Surg. 2004;130:617.
Treatment modalitiesTreatment modalities
Prospective Clinical Studies Reporting the Impact of Treatment With CPAPImpact of Treatment With CPAP on Asthma Outcome in Patients With Concomitant OSAS
Ann Allergy Asthma Immunol. 2008;101:350–357.
• ↑mean airway pressure
• Recruits underventilated alveoli
• ↑ minute ventilation,
• ↓ airways resistance
• Stabilizes upper aireways
• Prevents peripheral airways closure
Beneficial effects of CPAP in patients with asthma and OSAS “LOCAL”
↑ end-expiratory lung volume
↑ expiratory muscle function
↓ respiratory rate and dyspnea
↓ OSAS induce vagal stimulation
↓ OSAS induced increased intrathoracic pressure
Beneficial effects of CPAP in patients with asthma and OSAS
“ SYSTEMIC”
Impact of asthma asthma treatment on sleepsleep
OSASOSAS
OSAS TherapyOSAS Therapy
GERD therapyGERD therapy
GERDGERD
Does the treatment of OSA OSA by CPAP improve GERDGERD?
AuthorNResults
Kerr (1992)6 OSADecreased pH <4 esophageal exposure 6.3–0.1% (p<0.05)
Kerr (1993)6 non-OSADecreased pH <4 esophageal exposure 28–6% (p<0.05)
Ing (2000)
14 OSADecreased pH <4 esophageal exposure 12–4% (p<0.05)
Decreased overall number of reflux events (p<0.05)
8 non-OSADecreased pH <4 esophageal exposure 4–1% (p<0.05)
Decreased overall number of reflux events (p<0.05)
Green (2003)
165 OSA48% reduction in GERD symptom score (p<0.001)
While patients without CPAP had no improvement
Does Treatment of GERD GERD (PPI)(PPI) affect OSAOSA symptoms?
AuthorNMedication (t× time)Results
Ing (2000)6Nizatidine (30 days)50% AI reduction (p<0.05)
No significant reduction in AHISymptom reduction not evaluated
Senior (2001)10Omeprazole (30 days)31% AI reduction (p=0.04)
25% RDI reduction (p=0.06)Symptom reduction not evaluated
Steward (2004)27Pantoprazole (90 days)No significant reduction in AHI
Reduced daytime sleepiness (p=0.002)Reduced GERD symptoms (p=0.0006)
Mohamed-Mohamed-Hussein et al., Hussein et al., 20112011
34Pantoprazole ( 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)Obstructive sleep apnea (OSA) and asthma 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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Thank you for Thank you for staying awake!staying awake!
Or, you may now wake Or, you may now wake up and ask questions!up and ask questions!