231 OSA Bronchiect Tbm EDAC Lit Review
231.1 Summary
- OSA, Bronchiectasis, TBM, & EDAC
- Untreated OSA and Bronchiectasis/TBM: mechanisms
- Untreated OSA and Bronchiectasis/TBM: individual effects
- Untreated OSA and Bronchiectasis/TBM: society effects
- S, Sekibag Y, Musellim D. The frequency of obstructive sleep apnea in patients with non-cystic fibrosis bronchiectasis. Turk Thorac J. 2021; 22(4): 333-338.
- Faria J.nior NS, Urbano JJ, Santos IR et al. Evaluation ofobstructive sleep apnea in non-cystic fibrosis bronchiectasis: across-sectional study. PloS One. 2017;12(10):e0185413https://journals.plos.org/plosone/article?id10.1371/journal.pone.0185413
- TBM / EDAC and OSA
- DOI:10.1186/s41606-018-0030-2https://sleep.biomedcentral.com/articles/10.1186/s41606-018-0030-2
- 1986: Cole’s vicious cycle hypothesis environmental insult, genetic susceptibility, impaired mucociliary clearance -> persistents of microbes -> chronic inflammation -> tissue damage -> impaired motility -> vicious cycle [ citations 16 and 17 Cole, P.J. Inflammation: A two-edged sword—The model of bronchiectasis. Eur. J. Respir. Dis. Suppl. 1986, 147, 6–15 and King, P.T. The pathophysiology of bronchiectasis. Int. J. Chron. Obstruct. Pulmon. Dis. 2009, 4, 411–419.]
- High rate of nocturnal syndromes – unknown if mediated by OSA or non OSA sdb , or other mechanism – Gao et al (https://journals.plos.org/plosone/article?id10.1371/journal.pone.0102970) found 56.9% had elevated Pittsurgh Sleep Quality index (over 5) – double the rate in healthy subjects.
- Phua et al https://www.mdpi.com/2077-0383/6/12/114– airflow obstruction and gas trapping may worsen hypoxemia and hypercapnia related to apneas or hypopneas and thus lead to greater symptoms -
- “We hypothesize that, due to the irreversible dilatation of the bronchi, the presence of sputum, and airflow obstruction, patients with NCFB may be predisposed to hypoxemia during sleep, or to symptoms that may lead to arousal.” - https://journals.plos.org/plosone/article?id10.1371/journal.pone.0185413
231.2 Slide outline
231.2.1 Slide 1
- OSA, Bronchiectasis, TBM, & EDAC ### Slide 2
- Untreated OSA and Bronchiectasis/TBM: mechanisms
- 1986: Cole’s vicious cycle hypothesis environmental insult, genetic susceptibility, impaired mucociliary clearance -> persistents of microbes -> chronic inflammation -> tissue damage -> impaired motility -> vicious cycle [ citations 16 and 17 Cole, P.J. Inflammation: A two-edged sword—The model of bronchiectasis. Eur. J. Respir. Dis. Suppl. 1986, 147, 6–15 and King, P.T. The pathophysiology of bronchiectasis. Int. J. Chron. Obstruct. Pulmon. Dis. 2009, 4, 411–419.]
- High rate of nocturnal syndromes – unknown if mediated by OSA or non OSA sdb , or other mechanism – Gao et al (https://journals.plos.org/plosone/article?id10.1371/journal.pone.0102970) found 56.9% had elevated Pittsurgh Sleep Quality index (over 5) – double the rate in healthy subjects.
- Phua et al https://www.mdpi.com/2077-0383/6/12/114– airflow obstruction and gas trapping may worsen hypoxemia and hypercapnia related to apneas or hypopneas and thus lead to greater symptoms - ### Slide 3
- Untreated OSA and Bronchiectasis/TBM: individual effects
- “We hypothesize that, due to the irreversible dilatation of the bronchi, the presence of sputum, and airflow obstruction, patients with NCFB may be predisposed to hypoxemia during sleep, or to symptoms that may lead to arousal.” - https://journals.plos.org/plosone/article?id10.1371/journal.pone.0185413
- Good background on bronchiectasis – 2013 claims based derivation of incidence and prevalence https://journals.sagepub.com/doi/10.1177/1479972317709649
- Issues in bronchiectasis (3rd most common airway disease) – reference: https://journal.chestnet.org/article/S0012-3692(18)30392-1/fulltext
- Notable points: incidence is increasing, increases with age (similar to OSA?) – but is there an increased incidence? Neutrophilic infilitrate; ??? Other mechanistic overlap ### Slide 4
- Untreated OSA and Bronchiectasis/TBM: society effects
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7090178/
- Tianjin Hospital China; 124 consecutive patients with COPD 2017-2019 all received PSG. Not clear how many screened or if some were nonadherent
- Excluded asthma, pre-extisting bronchiectasis, nonsmokers, or any other diagnosed respiratory diseases
- 70 of 124 had overlap syndrome (COPD + OSA) – 56%
- Of that 70, 30 had radiographic bronchiectasis (42.86%) vs 10 of 54 without overlap.
- Sketchy study ### Slide 5
- S, Sekibag Y, Musellim D. The frequency of obstructive sleep apnea in patients with non-cystic fibrosis bronchiectasis. Turk Thorac J. 2021; 22(4): 333-338.
- 1 academic medical center clinic in istanbul – n75 patients over 1 year 2018; 24 decline study, 6 did not have available PSG results, 45 underwent testing. OSA in 55.8%: 14 mild, 5 moderate, 5 severe – despite average BMI 26.2. 86% symptomatic ### Slide 6
- Faria J.nior NS, Urbano JJ, Santos IR et al. Evaluation ofobstructive sleep apnea in non-cystic fibrosis bronchiectasis: across-sectional study. PloS One. 2017;12(10):e0185413https://journals.plos.org/plosone/article?id10.1371/journal.pone.0185413
- Sao Paulo Brazil – two bronchiectasis clinics 2013-16
- N418 patients narrowed to 129 -> 79 excluded based on discontinuing the protocol or not agreeindg. Rest had PSG, PFTs, Berlin+ESS and neck circumference.
- Most post-infectious bronchiectasis (though included some CF), half on azithro chr
- prevalence of OSA in patients with non-cystic fibrosis was 40.82%; despite normal BMI; majority had oxygen desaturation (38.7% <85%) – apparent additive effect with apneas. ### Slide 7
- TBM / EDAC and OSA
- T(B)M: trachea(-broncho) malacia – collapsibility of the cartilaginous portion of lower airway; differ based on whether the bronchi are involved. 50-80% a-p collapse during forced expiration may lead to symptoms.
- Thought predisposed by aspiration, LPR, GERD, and Chronic Cough
- SDB causal directly, or through those? Hypothesis – negative intrathoracic pressure during obstructions may cause increased tracheal compliance over time (Peters et al 2005)
- EDAC: excessive dynamic airway collapse / HDAC: hyperdynamic airway collapse: these refer to excessive movement of the membraneous form of the lower airway.
- In both conditions, the luminal area decreases, which leads to symptoms.
- Ehtisham 2015 - https://sleep.biomedcentral.com/articles/10.1186/s41606-018-0030-2 125 patients with TBM/HDAD; 62% had OSA by sleep study. Chart review at national jewish
- Peters et al 2005; https://pubmed.ncbi.nlm.nih.gov/16275417/ - individual case report of TM resolving with sleep apnea treatment; led to the hypothesis.
- TBM/EDAC can be successfully treated with CPAP (splinting open the airway during exhalation due to PEEP/EPAP) ### Slide 8
- DOI:10.1186/s41606-018-0030-2https://sleep.biomedcentral.com/articles/10.1186/s41606-018-0030-2
- Identified patients who all had sleep studies performed: N100 with OSA diagnostic code + HRCT; n100 with HRCT and no OSA diagnostic code (presumably negative study) Then, evaluated for the presence of TBM by expiratory tracheal collapse on the HRCT
- Findings: no strong relationship between tracheal collapse and weight, smoking, OSA diagnosis or severity by AHI. More related to supine AHI
- In sum, not supportive of causal role of OSA in causing TBM
231.3 Learning objectives
- OSA, Bronchiectasis, TBM, & EDAC
- Untreated OSA and Bronchiectasis/TBM: mechanisms
- Untreated OSA and Bronchiectasis/TBM: individual effects
- Untreated OSA and Bronchiectasis/TBM: society effects
- S, Sekibag Y, Musellim D. The frequency of obstructive sleep apnea in patients with non-cystic fibrosis bronchiectasis. Turk Thorac J. 2021; 22(4): 333-338.
231.4 Bottom line / summary
- OSA, Bronchiectasis, TBM, & EDAC
- Untreated OSA and Bronchiectasis/TBM: mechanisms
- Untreated OSA and Bronchiectasis/TBM: individual effects
- Untreated OSA and Bronchiectasis/TBM: society effects
- S, Sekibag Y, Musellim D. The frequency of obstructive sleep apnea in patients with non-cystic fibrosis bronchiectasis. Turk Thorac J. 2021; 22(4): 333-338.
231.5 Approach
- TODO: Outline the initial assessment or decision point.
- TODO: Outline the next diagnostic or management step.
- TODO: Outline follow-up or escalation criteria.
231.6 Red flags / when to escalate
- TODO: List red flags that require urgent escalation.
231.7 Common pitfalls
- TODO: Capture common errors or missed steps.
231.8 References
TODO: Add landmark references or guideline citations.