Chest
Volume 135, Issue 5, May 2009, Pages 1125-1132
Journal home page for Chest

Original Research
Sleep Medicine
Predictors of Habitual Snoring and Obstructive Sleep Apnea Risk in Patients With Asthma

https://doi.org/10.1378/chest.08-1273Get rights and content

Background

A high prevalence of obstructive sleep apnea (OSA) symptoms was reported in patients with asthma. Our goal was to evaluate factors associated with habitual snoring and OSA risk in these patients.

Methods

Patients with asthma were surveyed at specialty clinics with the Sleep Apnea scale of the Sleep Disorders Questionnaire (SA-SDQ) and questions about the frequency of asthma symptoms (National Asthma Education and Prevention Program guidelines), followed by medical record review. SA-SDQ scores ≥ 36 for men and ≥ 32 for women defined high OSA risk. Logistic regression was used to model associations with habitual snoring and high OSA risk.

Results

Among 244 patients, 37% snored habitually and 40% demonstrated high OSA risk. Independent predictors of habitual snoring included gastroesophageal reflux disease (GERD) [odds ratio (OR), 2.19; 95% confidence interval (CI), 1.19 to 4.02] and use of an inhaled corticosteroid (ICS) [OR, 2.66; 95% CI, 1.05 to 6.72]. High OSA risk was predicted by asthma severity step (OR, 1.59; 95% CI, 1.23 to 2.06), GERD (OR, 2.70; 95% CI, 1.51 to 4.83), and ICS use (OR, 4.05; 95% CI, 1.56 to 10.53). Linear, dose-dependent relationships of ICS with habitual snoring and high OSA risk were seen (p = 0.004 and p = 0.0006, respectively). Women demonstrated a 2.11 times greater odds for high OSA risk (95% CI, 1.10 to 4.09) when controlling for the above covariates.

Conclusions

Symptoms of OSA in patients with asthma are predicted by asthma severity, coexistent GERD, and use of an ICS in a dose-dependent fashion. The well-recognized male gender predominance for OSA symptoms is not apparent in these patients. Further exploration of these relationships may help to explain the increased prevalence of OSA in asthma and provide new insights into the reported female predominance of asthma morbidity.

Section snippets

Participants

The population included asthma patients returning for routine visits at the University of Michigan Pulmonary Clinics and Asthma-Airways Center. Patients 18 to 75 years old, able, and willing to provide informed consent and complete our survey were included. Those at urgent asthma-related visits and pregnant women were not enrolled. This study was approved by the University of Michigan Institutional Review Board and conducted between May 2004 and April 2006.

Survey Content

The self-administered survey included

Patient Characteristics

Of the 325 patients approached, 303 (93%) completed this survey. Nineteen patients with lung comorbidities (eg, COPD, interstitial lung diseases) were excluded from the analysis.

Among the 284 patients, 143 (50%) had a diagnosis of SDB or met the criteria for high OSA risk. Of the 75 patients (26%) with a known history of OSA and recommended treatment, 40 patients (25 of 49 women [51%] and 15 of 26 men [58%], p = 0.58) were receiving treatment with CPAP. As CPAP could influence asthma control,12

Discussion

This study identifies, for the first time, several factors that may help to explain an increased predisposition for OSA in asthma. Independent predictors of OSA symptoms included more severe asthma, history of GERD, and use of larger doses of ICSs, aside from traditional OSA risk factors such as excess weight and nocturnal nasal congestion. Additionally, these data suggest a reversal of male gender predominance for OSA symptoms in patients with asthma.

This specialty clinic-based, large sample

Acknowledgment

We thank Ashley S. Holland, MPH, Radu C. Nistor, and Jesica M. Pedroza, BS for assistance with administration of screening questionnaires in clinics and data entry. We recognize the help from the physicians at the University of Michigan Pulmonary Clinics and Briarwood Asthma-Airways Center in recruiting patients for this study.

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      In adults, obesity is the major risk factor linking asthma and OSA, and this can be augmented by frequent oral corticosteroid use resulting in myopathy, weight gain, and fat redistribution to the neck area. Independent of OCS, ICS are associated with habitual snoring and OSA in a dose-dependent manner.90 Prospective studies demonstrate an increased risk of incident OSA among patients with asthma;91-94 however, the relationship to asthma severity is inconsistent.

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    This work was performed at the University of Michigan Health System, Ann Arbor, MI.

    This research was supported by University of Michigan General Clinical Research Center grant MO1 RR00042 (to M.T.) and University of Michigan Department of Neurology Training Grant T32 NS007222 (to M.T.).

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (www.chestjournal.org/site/misc/reprints.xhtml).

    1

    Dr. Teodorescu has received funding from the University of Wisconsin School of Medicine and Public Health, Department of Medicine and from Medical Education and Research Committee New Investigator Award to continue asthma-sleep apnea research.

    2

    Dr. Coffey has received research funds from the University of Michigan.

    3

    Dr. Chervin has consulted on the subjects of sleep or sleep apnea for Respironics, Inc, Pavad Medical, Inc, Alexa Pharmaceuticals, Inc, several legal firms, and US District Attorney (each for under $10,000). He is named in a University of Michigan patent on a sleep apnea-related signal analysis algorithm. The other authors have no conflicts of interest to disclose.

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