Article
A longitudinal assessment of sleep variables during exacerbations of chronic obstructive pulmonary disease
Chronic Respiratory Disease 1–6 ª The Author(s) 2015 Reprints and permission: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1479972315587517 crd.sagepub.com
R Vanaparthy1, P Mota2,3, R Khan2,4, M Ehsan2,5, A Qureshi1, R ZuWallack1 and N Leidy6
Abstract Although sleep disturbance is common in chronic obstructive pulmonary disease (COPD), relatively little is known on the effect of the exacerbation on sleep quality. Accordingly, we longitudinally assessed sleep variables during exacerbations and clinical stability. This is a sub-study of a larger observational analysis. Inclusion criteria were clinically stable COPD and two or more clinical exacerbations in the preceding 12 months. Patients were followed for approximately 6 months and during this time the following were recorded daily: (1) COPD exacerbations, which were determined in two ways, clinically and symptom defined using the exacerbations of chronic pulmonary disease tool (EXACT); (2) daytime sleepiness, which was measured using the Stanford Sleepiness Scale; (3) subjective awakenings, which was measured from a sleep diary; and (4) sleep duration, efficiency, and objective awakenings, which was measured from actigraphy. These variables for exacerbation and non-exacerbation days were compared. Seventeen patients (9 male, age 63 + 12 years, forced expiratory volume in 1 second 52 + 20%) entered data over 135 + 18 days. During this time, 15 patients had 27 symptom-defined exacerbations and 8 had 9 clinically reported exacerbations. Symptom-defined exacerbation days were 26% of the total study days. More daytime sleepiness, decreased total sleep time (TST), and decreased sleep efficiency (SE) were present during exacerbations compared with clinical stability (p < 0.001). These disturbances tended to be greater during clinically reported exacerbations than during unreported events (p < 0.05). Increased daytime sleepiness, less TST, and poorer SE are present during COPD exacerbations. Keywords COPD, chronic obstructive, pulmonary disease, actigraphy, EXACT, sleep variables, exacerbation
Introduction Chronic obstructive pulmonary disease (COPD) is a progressive disease punctuated by exacerbations. The frequency of exacerbations in this disease ranges from approximately 0.85 to 2.00 per year for events associated with clinic visits1 and 3.2 per year in those sent home following a hospitalization for an exacerbation.2 Not only are exacerbations common, they result in substantial deteriorations in pulmonary function,3 respiratory symptoms,3,4 health-related quality of life,5 and physical activity and functional status.6,7 Despite the pervasive and substantial effect of the COPD exacerbation on the patient, relatively little information is known regarding its relationship to sleep variables. Accordingly, we assessed subjective daytime sleepiness and nighttime awakenings together
with objective sleep measures (total sleep time (TST), sleep efficiency (SE), and number of awakenings) longitudinally in COPD patients, comparing these
1
Pulmonary and Critical Care, St Francis Hospital and Medical Center, Hartford, CT, USA 2 University of CT School of Medicine, Farmington, CT, USA 3 Pulmonary and Critical Care, Tufts Medical Center, Boston, MA, USA 4 Pulmonary Medicine of Virginia Beach, Virginia Beach, VA, USA 5 SSM Health Care, St. Louis, MO, USA 6 Evidera, Bethesda, MD, USA Corresponding author: Richard ZuWallack, Pulmonary and Critical Care, St Francis Hospital and Medical Center, Hartford, CT 06105, USA. Email: [email protected]
Downloaded from crd.sagepub.com at CARLETON UNIV on July 6, 2015
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Chronic Respiratory Disease
variables during exacerbation and non-exacerbation (exacerbation-free) days.
Methods Study design This investigation was part of a longitudinal study that evaluated the effects of COPD exacerbations on physical activity and sleep. The relationship between exacerbations and directly measured physical activity—activity is significantly decreased on exacerbation days—has been reported.6 We now present the longitudinal data on sleep variables in this study. The study was approved by our hospital’s Institutional Review Board, and informed consent was obtained from all subjects. Inclusion criteria included (1) a clinical diagnosis of COPD, (2) a post-bronchodilator forced expiratory volume in 1 second (FEV1)/forced vital capacity
A longitudinal assessment of sleep variables during exacerbations of chronic obstructive pulmonary disease
Chronic Respiratory Disease 1–6 ª The Author(s) 2015 Reprints and permission: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1479972315587517 crd.sagepub.com
R Vanaparthy1, P Mota2,3, R Khan2,4, M Ehsan2,5, A Qureshi1, R ZuWallack1 and N Leidy6
Abstract Although sleep disturbance is common in chronic obstructive pulmonary disease (COPD), relatively little is known on the effect of the exacerbation on sleep quality. Accordingly, we longitudinally assessed sleep variables during exacerbations and clinical stability. This is a sub-study of a larger observational analysis. Inclusion criteria were clinically stable COPD and two or more clinical exacerbations in the preceding 12 months. Patients were followed for approximately 6 months and during this time the following were recorded daily: (1) COPD exacerbations, which were determined in two ways, clinically and symptom defined using the exacerbations of chronic pulmonary disease tool (EXACT); (2) daytime sleepiness, which was measured using the Stanford Sleepiness Scale; (3) subjective awakenings, which was measured from a sleep diary; and (4) sleep duration, efficiency, and objective awakenings, which was measured from actigraphy. These variables for exacerbation and non-exacerbation days were compared. Seventeen patients (9 male, age 63 + 12 years, forced expiratory volume in 1 second 52 + 20%) entered data over 135 + 18 days. During this time, 15 patients had 27 symptom-defined exacerbations and 8 had 9 clinically reported exacerbations. Symptom-defined exacerbation days were 26% of the total study days. More daytime sleepiness, decreased total sleep time (TST), and decreased sleep efficiency (SE) were present during exacerbations compared with clinical stability (p < 0.001). These disturbances tended to be greater during clinically reported exacerbations than during unreported events (p < 0.05). Increased daytime sleepiness, less TST, and poorer SE are present during COPD exacerbations. Keywords COPD, chronic obstructive, pulmonary disease, actigraphy, EXACT, sleep variables, exacerbation
Introduction Chronic obstructive pulmonary disease (COPD) is a progressive disease punctuated by exacerbations. The frequency of exacerbations in this disease ranges from approximately 0.85 to 2.00 per year for events associated with clinic visits1 and 3.2 per year in those sent home following a hospitalization for an exacerbation.2 Not only are exacerbations common, they result in substantial deteriorations in pulmonary function,3 respiratory symptoms,3,4 health-related quality of life,5 and physical activity and functional status.6,7 Despite the pervasive and substantial effect of the COPD exacerbation on the patient, relatively little information is known regarding its relationship to sleep variables. Accordingly, we assessed subjective daytime sleepiness and nighttime awakenings together
with objective sleep measures (total sleep time (TST), sleep efficiency (SE), and number of awakenings) longitudinally in COPD patients, comparing these
1
Pulmonary and Critical Care, St Francis Hospital and Medical Center, Hartford, CT, USA 2 University of CT School of Medicine, Farmington, CT, USA 3 Pulmonary and Critical Care, Tufts Medical Center, Boston, MA, USA 4 Pulmonary Medicine of Virginia Beach, Virginia Beach, VA, USA 5 SSM Health Care, St. Louis, MO, USA 6 Evidera, Bethesda, MD, USA Corresponding author: Richard ZuWallack, Pulmonary and Critical Care, St Francis Hospital and Medical Center, Hartford, CT 06105, USA. Email: [email protected]
Downloaded from crd.sagepub.com at CARLETON UNIV on July 6, 2015
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Chronic Respiratory Disease
variables during exacerbation and non-exacerbation (exacerbation-free) days.
Methods Study design This investigation was part of a longitudinal study that evaluated the effects of COPD exacerbations on physical activity and sleep. The relationship between exacerbations and directly measured physical activity—activity is significantly decreased on exacerbation days—has been reported.6 We now present the longitudinal data on sleep variables in this study. The study was approved by our hospital’s Institutional Review Board, and informed consent was obtained from all subjects. Inclusion criteria included (1) a clinical diagnosis of COPD, (2) a post-bronchodilator forced expiratory volume in 1 second (FEV1)/forced vital capacity
