Acute Oxygen in Patients with Sleep Apnea and COPD

doi:10.1378/chest.89.1.30

Chest

Volume 89, Issue 1, January 1986, Pages 30-38

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Nocturnal oxygen administered to patients with disordered breathing ameliorates hypoxemia. As a result, an important chemical stimulus to arousal is diminished. This could cause prolongation of disordered breathing events, worsen respiratory acidosis, and induce potentially harmful cardiac arrhythmias. The presence of chronic obstructive pulmonary disease (COPD) could further aggravate the situation since such patients may have depressed hypercarbic responses. To test this hypothesis, 20 obese men with sleep apnea and COPD were studied polysomnographically on two nights receiving air on one or oxygen at 4 L/min on the other. Supplemental oxygen increased mean DOB event duration from 25.7 to 31.4 seconds (p<0.001), increased end apneic Pco₂ from 52.8 to 62.3 mm Hg (p<0.025), and decreased mean end apneic pH from 7.34 to 7.28 (p<0.001). At the same time, it improved mean sleeping and end-apneic oxygen saturation. The number of ventricular extrasystoles (PVCs) per minute of sleep showed small increases in three subjects while breathing oxygen. Complex ventricular arrhythmias were unaffected by oxygen in five subjects. Oxygen eliminated atrioventricular block in two subjects. We conclude that nocturnal supplemental oxygen does not increase ventricular arrhythmias in the majority of patients with COPD and coexisting disordered breathing events. While the clinical significance of an oxygen associated increase in ventricular extrasystoles in three subjects is unclear, nocturnal monitoring by telemetry or ambulatory recorder should be sufficient to detect such patients.

Section snippets

Patient Population

We studied 20 men with previously established diagnosis of sleep apnea and COPD seen by the pulmonary service of the Houston Veterans Administration Medical Center between September 1982 and April 1984. Their mean age was 56.8 years, and all were obese (mean IBW = 162 percent ± 24). All subjects were cigarette smokers, (mean 71.3 pack years), and had symptoms or signs compatible with COPD, including chronic cough, dyspnea on exertion, or expiratory wheezing. Pulmonary function tests were

Results

Average disordered breathing event index (events per hour of sleep) for the group was 88.2 (±27) per hour of which 68 percent were apneas and 32 percent hypopneas. Eighteen subjects had right heart failure with chronic peripheral edema and right ventricular ejection fractions less than 45 percent. Since three of these also had left ventricular ejection fractions less than 50 percent, the diagnosis of cor pulmonale was made in only 15 subjects (Table 1). Results of pulmonary function tests are

Discussion

The purpose of this study was to monitor the cardiopulmonary effects of nocturnal oxygen in COPD patients with substantial numbers of sleep-related disordered breathing events. We believe that this issue is relevant to modern therapy since recent publications demonstrating the efficacy of home oxygen for hypoxemic COPD patients will undoubtedly lead to its wider use. The strong association of male sex, obesity, and age with disordered breathing¹⁰ and the recently described high prevalence of

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Cited by (62)

The effectiveness of supplemental oxygen and high-flow nasal cannula therapy in patients with obstructive sleep apnea in different clinical settings: A systematic review and meta-analysis
2023, Journal of Clinical Anesthesia
To evaluate the effectiveness of supplemental oxygen therapy and high-flow nasal cannula (HFNC) therapy in patients with obstructive sleep apnea (OSA) in different clinical settings to assess its application to surgical patients in the postoperative setting.
A systematic search was conducted on MEDLINE and other databases from 1946 to December 16th, 2021. Title and abstract screening were conducted independently, and the lead investigators resolved conflicts. Meta-analyses were performed using a random-effects model and are presented as mean difference and standardized mean difference with 95% confidence intervals. These were calculated using RevMan 5.4.
1395 and 228 OSA patients underwent oxygen therapy and HFNC therapy respectively.
Oxygen therapy and HFNC therapy.
Apnea-hypopnea index (AHI), oxyhemoglobin saturation (SpO₂), cumulative time with SPO₂ < 90% (CT90).
Twenty-seven oxygen therapy studies were included in the review, with ten randomized controlled trials (RCT), seven randomized crossovers, seven non-randomized crossovers, and three prospective cohorts. Pooled analyses showed that oxygen therapy significantly reduced AHI by 31% and increased SpO₂ by 5% versus baseline, and CPAP significantly reduced AHI by 84%, and increased SpO₂ by 3% versus baseline. CPAP was 53% more effective in reducing AHI than oxygen therapy, but both treatments had similar effectiveness in increasing SpO₂. Nine HFNC studies were included in the review, with five prospective cohorts, three randomized crossovers, and one RCT. Pooled analyses showed that HFNC therapy significantly reduced AHI by 36% but did not substantially increase SpO₂.
Oxygen therapy effectively reduces AHI and increases SpO₂ in patients with OSA. CPAP is more effective in reducing AHI than oxygen therapy. HFNC therapy is effective in reducing AHI. Although both oxygen therapy and HFNC therapy effectively reduce AHI, more research is needed to draw conclusions on clinical outcomes.
Sleep Deficiency, Sleep Apnea, and Chronic Lung Disease
2022, Clinics in Chest Medicine
Sleep-Related Breathing Complaints in Chronic Obstructive Pulmonary Disease
2022, Sleep Medicine Clinics
Oxygen Therapy in Sleep-Disordered Breathing
2021, Chest
Citation Excerpt :
NSO may be indicated when significant nocturnal hypoxia persists in patients with COPD despite optimal pharmacotherapy without seemingly increasing the risk of hypercapnia.20,44 However, oxygen may suppress the hypoxic respiratory drive, and as such, may contribute to prolonged duration of apnea in patients with OSA.18,19,25,45 In turn, this could lead to hypercapnia and acidosis in patients with OSA, especially in the setting of comorbid obstructive lung disease or hypoventilation.
Sleep-disordered breathing (SDB) is highly prevalent in adults and leads to significant cardiovascular and neurologic sequelae. Intermittent hypoxia during sleep is a direct consequence of SDB. Administration of nocturnal supplemental oxygen (NSO) has been used as a therapeutic alternative to positive airway pressure (PAP) in SDB. NSO significantly improves oxygen saturation in OSA but is inferior to PAP in terms of reducing apnea severity and may prolong the duration of obstructive apneas. The effect of NSO on daytime sleepiness remains unclear, but NSO may improve physical function-related quality of life in OSA. Its effects on BP reduction remain inconclusive. The effects of NSO vs PAP in OSA with comorbid COPD (overlap syndrome) are unknown. NSO is effective in reducing central sleep apnea related to congestive heart failure; however, its impact on mortality and cardiovascular clinical outcomes are being investigated in an ongoing clinical trial. In conclusion, studies are inconclusive or limited regarding clinical outcomes with oxygen therapy compared with sham or PAP therapy in patients with OSA and overlap syndrome. Oxygen does mitigate central sleep apnea. This review examines the crucial knowledge gaps and suggests future research priorities to clarify the effects of optimal dose and duration of NSO, alone or in combination with PAP, on cardiovascular, sleep, and cognitive outcomes.
Effect of One Night of Nocturnal Oxygen Supplementation on Highland Patients With OSA: A Randomized, Crossover Trial
2021, Chest
The treatment of OSA in highland residents is not established.
Does nocturnal oxygen supplementation (NOS) improve sleep-related breathing disturbances, nocturnal oxygenation, and cognitive performance in patients with OSA living at 3,200 m?
Forty patients with OSA permanently living in Shangri-La, China at 3,200 m (median age [interquartile range], 47.0 [44.0-53.0] years; oxygen desaturation index, 38.4/h [34.2/h-52.3/h]), were randomly assigned to receive nasal NOS and sham oxygen (ambient air), for one night each, at 2 L/min, in a crossover design, separated by a washout period of 2 weeks. During treatment nights polysomnography was performed, and further outcomes were evaluated the next morning. The primary outcome was the difference in apnea-hypopnea index (AHI) between nights with NOS and nights with sham oxygen.
During nights with sham oxygen, the median (interquartile range) total AHI was 43.4/h (31.1/h-67.5/h), the obstructive AHI was 41.9/h (28.5/h-66.8/h), and the central AHI was 0.6/h (0.1/h-1.3/h); blood oxygenation as determined by pulse oximetry (Spo₂) was 87.0% (84.5%-89.0%). In intention-to-treat analysis, NOS decreased the total AHI by a median of 17.9/h (95% CI, 8.0/h-27.1/h; P < .001), through a reduction in obstructive AHI by 16.0/h (95% CI, 6.8/h-26.0/h; P < .001) and central AHI by 0.4/h (95% CI, 0.1/h-0.9/h; P < .001). NOS also increased Spo₂ by 7.0% (95% CI, 6.0%-8.0%; P < .001). Heart rate during sleep and pulse rate in the morning after NOS were significantly reduced, but subjective sleep quality and cognitive performance showed no changes.
In highland residents with OSA, NOS significantly improved sleep-related breathing disturbances and nocturnal oxygenation. NOS also reduced heart rate during sleep and morning pulse rate. If these beneficial effects are confirmed in longer term studies, NOS may be a treatment option for highland patients with OSA who cannot be treated by CPAP.
Chinese Clinical Trial Registry; No.: ChiCTR1800017715; URL: http://www.chictr.org.cn/showproj.aspx?proj=29768
Hypoxia in the pediatric sleep lab: what (not) to do?
2020, Sleep Medicine
Citation Excerpt :
One can therefore assume that blunting of the hypoxic arousal response was the predominant factor causing this increase and that due to prolonged obstruction, CO2 levels increased during sleep. This increased duration of obstructive events due to supplemental oxygen has been previously described in adults with OSA and COPD and in other OSA patients as well [1,2]. On the other hand, infants with OSA can be succesfully treated with supplemental oxygen but this might be due to physiological differences in ventilatory control [3].

View all citing articles on Scopus

This investigation was supported in part by a grant from the Texas Affiliate of the American Heart Association and the General Medical Research Service of the Veterans Administration.

Manuscript received March 11; revision accepted July 16.

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Chest

Clinical InvestigationsAcute Oxygen in Patients with Sleep Apnea and COPD

Section snippets

Patient Population

Results

Discussion

Am J Med

Chest

Chest

Chest

Chest

Continuous or nocturnal oxygen therapy in hypoxemic chronic obstructive lung disease: a clinical tool

Ann Intern Med

Long-term domiciliary oxygen therapy in chronic hypoxic cor pulmonale complicating chronic bronchitis and emphysema

Lancet

Continuous oxygen therapy in chronic airway obstruction (observations on possible oxygen toxicity and survival)

Ann Intern Med

Chronic obstructive airflow disease and sleep studies

Am Rev Respir Dis

Effects of obesity on respiratory function

Am Rev Respir Dis

Chronic cor pulmonale

Am Rev Respir Dis

A manual of standardized terminology, techniques and scoring system for sleep stages of human subjects

Clinical Investigations
Acute Oxygen in Patients with Sleep Apnea and COPD