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Inhalers in a Patient with Obstructive Sleep Apnea: A Double-Edged Sword
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A7285 - Inhalers in a Patient with Obstructive Sleep Apnea: A Double-Edged Sword
Author Block: M. Kwon1, V. Arunthari2, A. S. Lee1, M. Mansukhani3, B. Colaco4; 1Pulmonary and Critical Care Medicine, Mayo Clinic Florida, Jacksonville, FL, United States, 2Pulmonary and Sleep Medicine, Mayo Clinic Jacksonville, Jacksonville, FL, United States, 3Sleep Medicine, Mayo Clinic, Rochester, MN, United States, 4Pulmonary and Sleep Medicine, Mayo Clinic Florida, Jacksonville, FL, United States.
Inhalers for obstructive lung disease are used to relieve lower airway obstruction. Obstructive sleep apnea (OSA) mostly involves the oropharynx or upper airway. When obstructive airways disease and sleep apnea-hypopnea syndrome co-exist in the same patient, both have to be managed simultaneously.
An 80 year-old woman with asthma who routinely used inhalers (corticosteroid, long and short-acting beta-agonists and anticholinergic) underwent sleep evaluation. She reported daytime somnolence, snoring and apneic episodes. She had a crowded oropharynx. Polysomnogram revealed mild OSA, worse during rapid eye movement (REM) sleep. Apnea Hypopnea Index (AHI) was 7.8 events per hour with a REM AHI of 29 events per hour. Continuous positive airway pressure (PAP) was poorly tolerated and subsequently bi-level PAP (BiPAP) in the spontaneous mode was attempted. IPAP of 13 and EPAP of 10cm H20 were ineffective with persistence of obstructive events. Higher pressures were poorly tolerated with increased leak and titration was deemed inadequate. Patient had not used her routine inhalers the day before due to PFT testing being scheduled. Repeat PAP titration with a full-face mask after resumption of inhaler regimen, was effective at a pressure of 6 cmH2O.
Frequently OSA patients have comorbid obstructive lung disease, using inhalers for their bronchodilator and anti-inflammatory effects for treatment. A possible anti-inflammatory effect of inhalers on the upper airway has been suggested, however inhalers are not recommended for the treatment of OSA. Prior research has demonstrated improved AHI after 3 months of inhaled corticosteroids. The short duration of abstinence suggests more of a placebo effect of inhalers and should be borne in mind in such patients. Prior research has also shown that steroid inhalers, among patients studied with MRI, have been associated with increased fat and volume distribution but have not affected severity of OSA based on PCrit measurement. Hence inhalers may have a multi-dimensional influence among these patients. Additionally, the use of a different and more traditional style full-face interface may have improved air leak and allowed for an effective titration at a lower pressure.
Inhaler therapy for obstructive airways disease may have a multi-dimensional influence on the severity and treatment of sleep apnea hypopnea syndrome.
Author Block: M. Kwon1, V. Arunthari2, A. S. Lee1, M. Mansukhani3, B. Colaco4; 1Pulmonary and Critical Care Medicine, Mayo Clinic Florida, Jacksonville, FL, United States, 2Pulmonary and Sleep Medicine, Mayo Clinic Jacksonville, Jacksonville, FL, United States, 3Sleep Medicine, Mayo Clinic, Rochester, MN, United States, 4Pulmonary and Sleep Medicine, Mayo Clinic Florida, Jacksonville, FL, United States.
Inhalers for obstructive lung disease are used to relieve lower airway obstruction. Obstructive sleep apnea (OSA) mostly involves the oropharynx or upper airway. When obstructive airways disease and sleep apnea-hypopnea syndrome co-exist in the same patient, both have to be managed simultaneously.
An 80 year-old woman with asthma who routinely used inhalers (corticosteroid, long and short-acting beta-agonists and anticholinergic) underwent sleep evaluation. She reported daytime somnolence, snoring and apneic episodes. She had a crowded oropharynx. Polysomnogram revealed mild OSA, worse during rapid eye movement (REM) sleep. Apnea Hypopnea Index (AHI) was 7.8 events per hour with a REM AHI of 29 events per hour. Continuous positive airway pressure (PAP) was poorly tolerated and subsequently bi-level PAP (BiPAP) in the spontaneous mode was attempted. IPAP of 13 and EPAP of 10cm H20 were ineffective with persistence of obstructive events. Higher pressures were poorly tolerated with increased leak and titration was deemed inadequate. Patient had not used her routine inhalers the day before due to PFT testing being scheduled. Repeat PAP titration with a full-face mask after resumption of inhaler regimen, was effective at a pressure of 6 cmH2O.
Frequently OSA patients have comorbid obstructive lung disease, using inhalers for their bronchodilator and anti-inflammatory effects for treatment. A possible anti-inflammatory effect of inhalers on the upper airway has been suggested, however inhalers are not recommended for the treatment of OSA. Prior research has demonstrated improved AHI after 3 months of inhaled corticosteroids. The short duration of abstinence suggests more of a placebo effect of inhalers and should be borne in mind in such patients. Prior research has also shown that steroid inhalers, among patients studied with MRI, have been associated with increased fat and volume distribution but have not affected severity of OSA based on PCrit measurement. Hence inhalers may have a multi-dimensional influence among these patients. Additionally, the use of a different and more traditional style full-face interface may have improved air leak and allowed for an effective titration at a lower pressure.
Inhaler therapy for obstructive airways disease may have a multi-dimensional influence on the severity and treatment of sleep apnea hypopnea syndrome.
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