SLEEP AND CYSTIC FIBROSIS A systematic review

Transcription

1 SLEEP AND CYSTIC FIBROSIS A systematic review Annual Israeli CF Society Conference, Fall 2016 "You lack the season of all natures, sleep William Shakespeare

2 METHODS Pubmed query: sleep AND cystic fibrosis 413 Title and abstract review identification of relevant articles 80 Data extraction Categorization: o Polysomnography o Oximetry o Ventilatory support o Pulmonary HTN o Questionnaires (QOL etc.) o Cough o Case reports o Reviews o Comments on papers o Other Sub-categorization: Pediatrics (24) Adults (27) Pediatrics & Adults (29)

3 RESULTS

4 RESULTS

5 Polysomnography Oximetry Ventilatory support Pulmonary HTN Questionnaires (QOL etc.) Cough Case reports Reviews Comments on papers Other Are there specific PSG findings in children with CF?

6 PSG Studies - Pediatric 1st au Year Journal Title n/age (control) Conclusion Waters 2016 J Cyst Fibros A cross-sectional analysis of daytime versus nocturnal polysomnographic respiratory parameters incystic fibrosis during early adolescence 46/8-12 Elevated RR during SWS; mild CO2 retention in REM. These incorporated into a model correlating with FEV1. Silva 2016 Rev Port Pneumol Paranjape 2015 Pediatrics Respiratory sleep disturbance in children and adolescents with cystic fibrosis Polysomnographic Markers in Children With Cystic Fibrosis Lung Disease 33/ /9.6±3.6 (10) 87.9% presented sleep complaints. SE reduced; SOL, WASO increased. N1 increased. AHI, RDI, mean awaking and sleep SpO2 normal CF children compared w/matched snoring ct s. CF lower sats (95%±1.6% vs 98%±0.6%), higher RR(19.5±4.9 vs 16.5±1.2), higher proportion of inspiratory NREM flow limitation. No dif in RDI. Abnormalities independent of weight and lung function Ramos 2013 J Bras Pneumol Nocturnal hypoxemia in children and adolescents with cystic fibrosis 67/ 2-14 Nocturnal hypoxemia correlated with the severity of lung disease, FEV1, FVC, AI, AHI Spicuzza 2012 Arch Pediatr Adolesc Med Early occurrence of obstructive sleep apnea in infants and children with cystic fibrosis 40/ (control age match) CF lower noctur mean SaO2. AHI higher in CF, partic preschool & w/up aw abnorm. 70%mild-mod OSA AHI >2. SE reduced w/cf, less REM, increased AI Van der giessen 2012 Pediatr Pulmonol Nocturnal oxygen saturation in children with stable cystic fibrosis 22/ 6-18 Nocturnal O2 saturation w/stable CF is lower than healthy children; correlated with lung function & CT Ramos 2009 Int J Pediatr Otorhinolaryngol Evaluation of the upper airway in children and adolescents with cystic fibrosis and obstructive sleep apnea syndrome 63/2-14 Cross sectional observational study showing upp AW Bone & soft tissue structural changes & chronic rhinosinusitis associated with OSAS. ENT study of findings in pt's with OSA Neqvi 2008 Sleep Breath Sleep architecture in children and adolescents with cystic fibrosis and the association with severity of lung disease 24/ (14) frequent sleep complaints & alteration in architect (dec SE, REM% long REM lat). magnitude associated w/severity of lung dis, but not directly correlated w/nocturnal hypoxemia or hypovent Villa 2001 Arch Dis Child Nocturnal oximetry in infants with cystic fibrosis 19(20)/13m3-36m lower mean SaO2 & higher %TST w/sao2 <93% in symptomatic children than in controls Avital 1991 Am Rev Respir Dis Effect of theophylline on lung function tests, sleep quality, and nighttime SaO2 in children with cystic fibrosis. 12/7-17 lower heart rate, better sats, but theoph disrupted sleep - lower SE, tot wake time. No effect on AHI or PLMS Tepper 1983 chest Ventilation and oxygenation changes during sleep in cystic fibrosis 6/10-16 hypoventilation during REM may contribute to oxygen desaturation in patients with cystic fibrosis

7 PSG Studies - Pediatric Background: Along with lower aw involvement, patients commonly exhibit upper aw inflammation and obstruction Chronic or acute inflammation is a common cause of upper aw collapse during sleep determining obstructive apneic events Objective - to assess the occurrence of SDB, nocturnal hypoxemia, and sleep architecture in a cohort of infants and children with CF and mild lung impairment in stable condition Methods: Parameters: Resting O2 sats, spirometry, PSG Exclusion criteria Exacerbation, chronic O2, FEV1<60%, oral steroid therapy Controls healthy volunteers

8 PSG Studies - Pediatric 70% of CF pt s AHI 2 (OSA) ~½ mild OSA No correlation between FEV1 & mean sleep sats Upper aw eval all but 1 child with AT hypertrophy or chronic rhinosinusitis had OSA

9 PSG Studies - Pediatric

10 PSG Studies - Pediatric

11 PSG Studies - Pediatric Summary: Lower nocturnal mean SaO2 Increased risk of OSA - preschool & w/upper aw abnormality SE reduced, less REM, increased AI Neurobehavioral Metabolic Cardiovascular Inflammatory

12 PSG Studies - Pediatric 1st au Year Journal Title n/age (control) Conclusion Waters 2016 J Cyst Fibros A cross-sectional analysis of daytime versus nocturnal polysomnographic respiratory parameters incystic fibrosis during early adolescence 46/8-12 Elevated RR during SWS; mild CO2 retention in REM. These incorporated into a model correlating with FEV1. Silva 2016 Rev Port Pneumol Paranjape 2015 Pediatrics Respiratory sleep disturbance in children and adolescents with cystic fibrosis Polysomnographic Markers in Children With Cystic Fibrosis Lung Disease 33/ /9.6±3.6 (10) 87.9% presented sleep complaints. SE reduced; SOL, WASO increased. N1 increased. AHI, RDI, mean awaking and sleep SpO2 normal CF children compared w/matched snoring ct s. CF lower sats (95%±1.6% vs 98%±0.6%), higher RR(19.5±4.9 vs 16.5±1.2), higher proportion of inspiratory NREM flow limitation. No dif in RDI. Abnormalities independent of weight and lung function Ramos 2013 J Bras Pneumol Nocturnal hypoxemia in children and adolescents with cystic fibrosis 67/ 2-14 Nocturnal hypoxemia correlated with the severity of lung disease, FEV1, FVC, AI, AHI Spicuzza 2012 Arch Pediatr Adolesc Med Early occurrence of obstructive sleep apnea in infants and children with cystic fibrosis 40/ (control age match) CF lower noctur mean SaO2. AHI higher in CF, partic preschool & w/up aw abnorm. 70%mild-mod OSA AHI >2. SE reduced w/cf, less REM, increased AI Van der giessen 2012 Pediatr Pulmonol Nocturnal oxygen saturation in children with stable cystic fibrosis 22/ 6-18 Nocturnal O2 saturation w/stable CF is lower than healthy children; correlated with lung function & CT Ramos 2009 Int J Pediatr Otorhinolaryngol Evaluation of the upper airway in children and adolescents with cystic fibrosis and obstructive sleep apnea syndrome 63/2-14 Cross sectional observational study showing upp AW Bone & soft tissue structural changes & chronic rhinosinusitis associated with OSAS. ENT study of findings in pt's with OSA Neqvi 2008 Sleep Breath Sleep architecture in children and adolescents with cystic fibrosis and the association with severity of lung disease 24/ (14) frequent sleep complaints & alteration in architect (dec SE, REM% long REM lat). magnitude associated w/severity of lung dis, but not directly correlated w/nocturnal hypoxemia or hypovent Villa 2001 Arch Dis Child Nocturnal oximetry in infants with cystic fibrosis 19(20)/13m3-36m lower mean SaO2 & higher %TST w/sao2 <93% in symptomatic children than in controls Avital 1991 Am Rev Respir Dis Effect of theophylline on lung function tests, sleep quality, and nighttime SaO2 in children with cystic fibrosis. 12/7-17 lower heart rate, better sats, but theoph disrupted sleep - lower SE, tot wake time. No effect on AHI or PLMS Tepper 1983 chest Ventilation and oxygenation changes during sleep in cystic fibrosis 6/10-16 hypoventilation during REM may contribute to oxygen desaturation in patients with cystic fibrosis

13 Polysomnography Oximetry Ventilatory support Pulmonary HTN Questionnaires (QOL etc.) Cough Case reports Reviews Comments on papers Other Are there nocturnal oximetry findings in children with CF?

14 Oximetry Studies 1st au Year Journal Title Variables n/age (control) Conclusion PEDS Uyan 2014Pediatr Pulmonol Factors that correlate with sleep oxygenation in children with cystic fibrosis pft, O2 sat, 6MWT, S K, Brasfield & CT scores, BGs, nut status 24/ In CF children w/nl PFT or mild-mod lung dis, nocturnal oxygenation may correlate with S K, Brasfield and CT scores as well as PaO2, SaO2, z-score of weight and height Pradal 1990Pediatr Pulmonol Transcutaneous blood gas analysis during sleep and exercise in cystic fibrosi Noct/exercise sats, BG, PFTt 40/ difficulties limit the usefulness of long-term but not shortterm recordings ADULTS Frangolias 2001 Chest Noct (home) Predictability of oxygen desaturation SpO2, resting & during sleep in patients with cystic fibrosis : exercise SpO2. S- clinical, spirometric, and exercise parameters K score 70/ spirometry & wake sat limited in predicting nocturnal desat Montgomery 1989Pediatr Pulmonol Home measurement of oxygen saturation during sleep in patients with cystic fibrosis noct sats, clinical score, spirometry, ABG 14/? severity of hemoglobin desaturation during sleep could not be reliably predicted from clinical scores or awake pulmonary function Only abstract only partial info PEDS +ADULTS Braggion 1992Acta Paediatr Hemoglobin desaturation during sleep and daytime in patients with cystic fibrosis and severe airway obstruction noct/day sats, clinical/radiol scores, PFT, ABG 31/15.2( ) Clinical, radiological scores & spirometry showed a poor correlation with both overnight and daytime desaturation Coffey 1991 Chest Comparison of oxygen desaturation during sleep and exercise in patients with cystic fibrosis sleep/daytime/ exercise sat, PFT 21/14-39 clinically significant oxygen desaturation during sleep may be missed unless specifically checked. awake and exercise SaO2 may not give an indication of the degree of sleeprelated desaturation Versteegh 1990Eur Respir J Relationship between airway obstruction, desaturation during exercise and nocturnal hypoxaemia sleep/daytime/ exercise sat, PFT 16/10-22 resting So2 in the sitting position lower than 94%- most predictive of nocturnal desat and indicates a risk of nocturnal hypoxaemia in patients with cystic fibrosis

15 Polysomnography Oximetry Ventilatory support Pulmonary HTN Questionnaires (QOL etc.) Cough Case reports Reviews Comments on papers Other Does NIV improve children with CF?

16 Vent Support Studies 1st au year Journal Title Variables n/age (control) Conclusion PEDS Caronia 1998 Clin Pediatr (Phila) Use of bilevel positive airway pressure (BIPAP) in end-stage patients with cystic fibrosis awaiting lung transplantation 9 case series. End stage pt's. improvement w/bipap awaiting transplant ADULTS Young 2008 Thorax Randomised placebo controlled trial of noninvasive ventilation for hypercapnia in cystic fibrosis CFQoL, ESS, PSQI, dyspnoea Scale, Sleep Disturb, PSG, PFT, neurocog test 8/ wks noct NIV improves chest symptoms, exertional dyspnoea, noct hypovent & peak exercise capacity in adult pts w/stable CF & awake hypercapnia. Sleep architecture, PFT unchanged Granton 2002 Respir Care Noninvasive nocturnal ventilatory support in advanced lung disease from cystic fibrosis PSG, abg, pft, 2months. NPPV is well tolerated by 8. Subjective but not exercise capacity, objective NPPV did not improve objective (sleep quality, 13, 8 completed health-related daytime abgs, pft, resp muscle strength, exercise QOL tolerance). Good for bridge to transplant Milross 2001 Low-flow oxygen and bilevel ventilatory Am J Respir Crit Care support: effects on ventilation Med during sleep in cystic fibrosis PSG 13/ comparison of RA,low flow O2 & bilevel for mod to sev CF. Min vent wake& NREM>REM in all but bilevel. Both improved O2sat Gozal 1998 Eur Respir J Nocturnal ventilatory support in patients with cystic fibrosis: comparison with supplemental oxygen PSG 6/ Bipap compared w/low flow O2. Both improved O2 REM/NREM.CO2 increased w/o2, improved REM &NREM w/bilev. Sleep architect & AI unchanged Regnis 1994 Chest Benefits of nocturnal nasal CPAP in patients with cystic fibrosis. PSG, PFT, ABG 7/25+-8 CF w/sev lung dis. eval 2 nights, control/ncpap on RA/O2. All showed desats & RDI on control night. ncpap improved, RDI, O2, not CO2, SE, TST Piper 1992 Chest Nocturnal nasal IPPV stabilizes patients with cystic fibrosis and hypercapnic respiratory failure. 4/25-30 pts w/resp failure. 3 failed cpap. Did well with NIPPV. Improved sleep and daytime activity PEDS +ADULTS Efrati 2004 Isr Med Assoc J Long-term non-invasive positive pressure ventilation among cystic fibrosis patients awaiting lung transplantation ABG, PFT, morn headache, activity, sleep pattern 9/13-40 long term nippv improved ventilation, abg, bmi and subjective sleep quality, morn headaches, daily activity level

17 Polysomnography Oximetry Ventilatory support Pulmonary HTN Questionnaires (QOL etc.) Cough Case reports Reviews Comments on papers Other Are there behavioral sleep problems in children with CF?

18 Questionnaire Studies 1st au year Journal Title Variables n/age (control) Conclusion PEDS Meltzer 2012 Poorer perceived health was associated with sleep Child Health Sleep Patterns in Children with Cystic Fibrosis CSHQ, CHQ 45(45)/3-12 disturbances among children with CF, but not for children Care without CF Ward 2009 Arch Dis Child Problem behaviours and parenting in preschool children with cystic fibrosis Surveys - sleep, eat, behav. How much is your child s sleep a problem for you? no/sm/mod/lrg problem 117/0.5-5 problems w/ sleep common in cf Amin 2005 Chest ADULTS The relationship between sleep disturbance and pulmonary function in stable pediatric cystic fibrosis patients actigraphy, sleep questionnaires, PFT 44(40)/ 11.9±2.8 CF w/stable PFT have lower SE, more frequent noct awakenings than controls. Sig correlation between sleep parameters and FEV1. These suggest a bidirectional relationship Forte 2015 Respir Care Relationship Between Clinical Variables and Health-Related Quality of Life in Young Adult Subjects With Cystic Fibrosis Association between WHOQOL-BREF & CFQOL & clinical, PFT, sleep quality, PSG, ESS, PSQI, 6MWT, echo 51 PSQI, 6MWD, ESS, FEV1 were predictors of WHOQOL-BREF scores. Age at dx, clinical score, PSQI, 6MWD, sex, AHI, BMI, age, AI, FEV1, pulm art sys press were predictors of CFQOL scores Bouka 2012 Respir Med Quality of life in clinically stable adult cystic fibrosis out-patients: associations with daytime sleepiness and sleep quality HRQoL, CFQ18+R, ESS, PSQI 55(30) Higher ESS, PSQI. correlated with lower CFQ18 þ R scores for vitality, emotional functioning, social, role, eating disturbances and digestive symptoms Flume 2009 J Cyst Fibros Patient-reported pain and impaired sleep quality in adult patients with cystic fibrosis brief pain inventory, PSQI 50 strong correlation between pain and sleep quality in cf Jankelowitz 2005 Chest Cystic fibrosis patients have poor sleep quality despite normal sleep latency and efficiency ESS, PSQI, Medical Outcomes Study 36- item short form. Actigraphy 20(20)/ 25.85±6 CF pts had higher PSQIs, higher fragmentation index (FI), & less immobile time. There was a significant correlation of FI with FEV(1) and PSQI scores Congleton 1996 Thorax Quality of life in adults with cystic fibrosis Nottingham Health Profile 240/26(15-26) Men trend to worse perceived QOL including sleep. Women not. Similar to other minor non-acute conditions

19 Questionnaire Studies How much is your child s sleeping pattern or habits a problem for you? No vs small vs moderate/large Control data - the Longitudinal Study of Australian Children (LSAC) Mild to severe sleep problems were more common in children with CF than in healthy children 53.5% across all ages(vs. 38.8%) 61.1% year old (vs. 33.5%)

20 Questionnaire Studies Meltzer 2012 Amin 2005 Chest Child Health Care Sleep Patterns in Children with Cystic Fibrosis CSHQ, CHQ 45(45)/3-12 The relationship between sleep disturbance and pulmonary function in stable pediatric cystic fibrosis patients actigraphy, sleep questionnaires, PFT 44(40)/ 11.9±2.8 Poorer perceived health was associated with sleep disturbances among children with CF, but not for children without CF CF w/stable PFT have lower SE, more frequent noct awakenings than controls. Sig correlation between sleep parameters and FEV1. These suggest a bidirectional relationship Meltzer et al: Children with CF wake on average 18 minutes earlier, sleep 30 minutes less, and have more symptoms of SDB Data suggestive preschoolers w/cf have more stalling behaviors at bedtime & later bedtime Associations - children w/cf who are perceived to have poorer health also have more sleep disruptions Amin et al: Lower SE & duration correlated w/fev1 Parent & Child Questionnaires CF pt s more frequent: Awakenings with cough, for bathroom use (defec), difficulty initiating sleep & watching of TV at bedtime

21 Polysomnography Oximetry Ventilatory support Pulmonary HTN Questionnaires (QOL etc.) Cough Case reports Reviews Comments on papers Other PEDS 1st au year Journal Title Variables n/age (range) Conclusion Van Der Giessen ADULTS 2009 Pediatr Pulmonol Nocturnal cough in children with stable cystic fibrosis cough recording, PFT, CT, O2 sat, diary 25/13(6-19) Nocturnal coughing w/cf higher than described for nl children. More sev w/advanced dis. Mostly 1st h of sleep than gradually less. Variability noted night to night Kerem 2011 J Cyst Fibros Ambulatory quantitative waking and sleeping cough assessment in patients with cystic fibrosis cough rate, PFT 19/26(19-57) Subjective report consistent with objective day-night difference but not objective wake cough

22 Polysomnography Oximetry Ventilatory support Pulmonary HTN Questionnaires (QOL etc.) Cough Case reports Reviews Comments on papers Other

23 Case Reports 1st au year Journal Title Age Conclusion PEDS Macdonald 2009 Respir Care Hayes 2006 Sleep Med Primary snoring and growth failure in a patient with cystic fibrosis Obstructive sleep apnea syndrome: a potential cause of lower airway obstruction in cystic fibrosis 8 yo Adenotonsillar hypertrophy w/rec pharyngitis and primary snoring might hinder growth in cf 6 yo Resolution of resp decline after T&A 6 yo Female w/cf & PS 8 yo Female w/cf, PI & JRA Presents w/6 month Hx of: Presents w/1 y Hx of: Intermittent wet cough Few exacerbations Wt loss th %ile PE tonsillar hypertrophy FEV % No reponse to ABX On F/U mom reports snoring, witnessed apneas Rec pharyngitis, multiple otitides, URIs & acute sinusitis Wt loss th <3 rd %ile Snoring & mouth breathing PE tonsillar hypertrophy FEV1 95% PSG OSA (AHI 10/h) Following T&A Resolution of resp symptoms Wt to 50 th %ile FEV1 97% PSG flow limitation, no OSA (AHI 0.2/h), but atypically good night, UARS Following T&A Resolution of symptoms Wt to 25 th -50 th %ile FEV1 109%

24 Polysomnography Oximetry Ventilatory support Pulmonary HTN Questionnaires (QOL etc.) Cough Case reports Comments on papers Other/Reviews Reviews

25 Other Yilmaz 2008 J Cyst Fibros Sleep quality and depression-anxiety in mothers of children with two chronic respiratory diseases: asthma and cystic fibrosis PSQI, HADS (hospital anxiety depression scale) Respiratory disease in a child may be associated with disturbed sleep quality and increased depression and anxiety in mothers (most not sig) Reviews 1st au year Journal Title Type Conclusion Allen 2016 CNS Neurosci Ther Sleep and Pain in Pediatric Illness: A Conceptual Review Review General lit suggests a pain sleep connection. Studies show pain and sleep problems in CF. None have studied the connection Lee 2016 Chron Respir Dis Pain and its clinical associations in individuals with Review cystic fibrosis: A systematic review Musculoskeletal pain in CF children - not associated w/disease severity but associated w/qol etc. including sleep disturbance. In CF adults pain negatively influenced sleep

26 Summary Since the 80 s 80 articles have been published on sleep & CF PSG, oximetry lower SE, more arousals, lower sats, more OSA in young children, desaturations correlated w/disease severity CF patients sleepy NIV small studies, advanced disease, improves gas exchange, may improve symptoms Questionnaires sleep difficulties common in pediatric CF patients Nocturnal cough more than healthy but less than diurnal

27 But, more research is needed Examples: T&A for pediatric OSA in CF Correlation of OSA & pulmonary exacerbations Restless Legs Syndrome & CF QUESTIONS?