Elsevier

Sleep Medicine Reviews

Volume 18, Issue 2, April 2014, Pages 165-171
Sleep Medicine Reviews

Clinical review
Obstructive sleep apnea and asthma: Associations and treatment implications

https://doi.org/10.1016/j.smrv.2013.04.004Get rights and content

Summary

Obstructive sleep apnea (OSA) and asthma are highly prevalent respiratory disorders and are frequently co-morbid. Risk factors common to the two diseases include obesity, rhinitis, and gastroesophageal reflux (GER). Observational and experimental evidence implicates airways and systemic inflammation, neuromechanical effects of recurrent upper airway collapse, and asthma-controlling medications (corticosteroids) as additional explanatory factors. Therefore, undiagnosed or inadequately treated OSA may adversely affect control of asthma and vice versa. It is important for clinicians to be vigilant and specifically address weight-control, nasal obstruction, and GER in these populations. Utilizing validated screening instruments to affirm high risk of co-morbid OSA or asthma in persistently symptomatic patients will allow clinicians to cost-effectively test and treat appropriate patients, potentially improving outcomes. While non-invasive ventilation in acute asthma improves outcomes, the role of chronic continuous positive airway pressure (CPAP; the first-line treatment for OSA) in improving long-term asthma control is not known. Future research should focus on the impact of optimal CPAP therapy and adherence on asthma symptoms and outcomes.

Introduction

Obstructive sleep apnea (OSA) and asthma are highly prevalent chronic respiratory disorders that share several risk factors for disease expression and progression. Both symptoms of OSA and diagnosed OSA are more frequent in clinical populations with asthma compared to other populations.1, *2, 3 In addition to overlapping risk factors, multiple evidence-based and hypothetical mechanisms have been postulated to explain the frequent co-existence of OSA and asthma, also referred to as the “alternative overlap syndrome”.4, 5, 6 However, the effects of the direct pathophysiologic consequences of OSA (e.g., chronic intermittent hypoxemia, circadian alteration of autonomic functions, and increased intrathoracic pressure swings related to the occluded upper airway) on the clinical severity of asthma are poorly understood. Similarly, the impact of continuous positive airway pressure (CPAP), a first-line treatment of OSA, on asthma symptoms and quality of life remain unclear.

Here we discuss the epidemiologic and mechanistic evidence supporting the association of OSA with asthma in adults, with emphasis on studies published in the last five years and those examining the effects of standard therapies for OSA on asthma outcomes.

Section snippets

Epidemiologic studies of OSA and asthma overlap

The prevalence of OSA in the adults is estimated at 2–4% in the general population.7 Several studies have described the prevalence of OSA based on snoring, validated screening questionnaires, and objective tests such as polysomnography in populations with allergic airways disease, nocturnal asthma, and severe or poorly-controlled asthma. In a general population European study, a 17% prevalence of snoring and 14% of witnessed apneas was reported in those with physician-diagnosed asthma, compared

Potential mechanisms of increased OSA risk in asthma

Asthma is a chronic inflammatory disease associated with variable airflow obstruction and bronchial hyper-responsiveness.10 The relationship of chronic airway inflammation to the clinical symptoms of asthma (wheezing, dyspnea, and cough) has been well described.10 However, our knowledge is limited regarding the impact of asthmatic airway inflammation on the development or worsening of OSA. The persistent airway mucosal inflammation that occurs in asthma can promote a reduction in the surface

Potential effects of pathophysiologic consequences of OSA on asthma

Direct adverse effects of repeated upper airway collapse during sleep in OSA include exaggerated intrathoracic pressure changes, chronic intermittent hypoxia, and sleep fragmentation. Here we discuss how these changes directly and through intermediate pathways moderate the expression of asthma.

Overlap of OSA and asthma: implications for treatment

Based on the preceding discussion, it is reasonable to expect an effective therapy for OSA to favorably impact subjective and objective asthma control and vice versa. Early studies examined the role of non-invasive ventilation (NIV) in acute respiratory failure secondary to asthma and reported improvements in gas exchange and reduction in rates of mechanical ventilation.84, 85 However, the role of NIV in severe acute asthma remains controversial.86 Another recent report suggests that CPAP may

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