Long term management of obstructive sleep apnea and its comorbidities

Obstructive sleep apnea (OSA) is a worldwide highly prevalent disease associated with systemic consequences, including excessive sleepiness, impairment of neurocognitive function and daytime performance, including driving ability. The long-term sequelae of OSA include and increase risk for cardiovascular, cerebrovascular and metabolic syndrome disorders that ultimately lead to premature death if untreated. To ensure optimal long-term outcomes, the assessment and management of OSA should be personalized with the involvement of the appropriate specialist. Most studies have demonstrated inmediate improvement in daytime somnolence and quality of life with CPAP and other therapies, but the effect of long-term treatment on mortality is still under debate. Currently, the long-term management of OSA should be based on a) identifying physiological or structural abnormalities that are treatable at the time of patient evaluation and b) comprehensive lifestyle interventions, especially weight-loss interventions, which are associated with improvements in OSA severity, cardiometabolic comorbidities, and quality of life. In long-term management, attention should be paid to the clinical changes related to a potential reoccurrence of OSA symptoms and it is also necessary to monitor throughout the follow up how the main associated comorbidities evolve

Obesity as an adipose tissue dysfunction disease and a risk factor for infections – Covid-19 as a case study

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS CoV2) disease (COVID-19) is a novel threat that hampers life expectancy especially in obese individuals. Though this association is clinically relevant, the underlying mechanisms are not fully elucidated. SARS CoV2 enters host cells via the Angiotensin Converting Enzyme 2 receptor, that is also expressed in adipose tissue. Moreover, adipose tissue is also a source of many proinflammatory mediators and adipokines that might enhance the characteristic COVID-19 cytokine storm due to a chronic low-grade inflammatory preconditioning. Further obesity-dependent thoracic mechanical constraints may also incise negatively into the prognosis of obese subjects with COVID-19. This review summarizes the current body of knowledge on the obesity-dependent circumstances triggering an increased risk for COVID-19 severity, and their clinical relevanc

Somatotypes trajectories during adulthood and their association with COPD phenotypes

Rationale: Chronic obstructive pulmonary disease (COPD) comprises distinct phenotypes, all characterised by airflow limitation. Objectives: We hypothesised that somatotype changes – as a surrogate of adiposity – from early adulthood follow different trajectories to reach distinct phenotypes. Methods: Using the validated Stunkard’s Pictogram, 356 COPD patients chose the somatotype that best reflects their current body build and those at ages 18, 30, 40 and 50 years. An unbiased group-based trajectory modelling was used to determine somatotype trajectories. We then compared the current COPD-related clinical and phenotypic characteristics of subjects belonging to each trajectory. Measurements and main results: At 18 years of age, 88% of the participants described having a lean or medium somatotype (estimated body mass index (BMI) between 19 and 23 kg·m−2 ) while the other 12% a heavier somatotype (estimated BMI between 25 and 27 kg·m−2 ). From age 18 onwards, five distinct trajectories were observed. Four of them demonstrating a continuous increase in adiposity throughout adulthood with the exception of one, where the initial increase was followed by loss of adiposity after age 40. Patients with this trajectory were primarily females with low BMI and DLCO (diffusing capacity of the lung for carbon monoxide). A persistently lean trajectory was seen in 14% of the cohort. This group had significantly lower forced expiratory volume in 1 s (FEV1), DLCO, more emphysema and a worse BODE (BMI, airflow obstruction, dyspnoea and exercise capacity) score thus resembling the multiple organ loss of tissue (MOLT) phenotype. Conclusions: COPD patients have distinct somatotype trajectories throughout adulthood. Those with the MOLT phenotype maintain a lean trajectory throughout life. Smoking subjects with this lean phenotype in early adulthood deserve particular attention as they seem to develop more severe COPD

Long term management of obstructive sleep apnea and its comorbidities

Obstructive sleep apnea (OSA) is a worldwide highly prevalent disease associated with systemic consequences, including excessive sleepiness, impairment of neurocognitive function and daytime performance, including driving ability. The long-term sequelae of OSA include and increase risk for cardiovascular, cerebrovascular and metabolic syndrome disorders that ultimately lead to premature death if untreated. To ensure optimal long-term outcomes, the assessment and management of OSA should be personalized with the involvement of the appropriate specialist. Most studies have demonstrated inmediate improvement in daytime somnolence and quality of life with CPAP and other therapies, but the effect of long-term treatment on mortality is still under debate. Currently, the long-term management of OSA should be based on a) identifying physiological or structural abnormalities that are treatable at the time of patient evaluation and b) comprehensive lifestyle interventions, especially weight-loss interventions, which are associated with improvements in OSA severity, cardiometabolic comorbidities, and quality of life. In long-term management, attention should be paid to the clinical changes related to a potential reoccurrence of OSA symptoms and it is also necessary to monitor throughout the follow up how the main associated comorbidities evolve

Hipoxemia nocturna y diámetro de arteria pulmonar en fumadores con/sin Enfermedad Pulmonar Obstructiva Crónica

Antecedentes: El ensanchamiento anormal de la arteria pulmonar (EAP) detectado mediante tomografía axial computarizada de tórax (TAC) está asociado con peores resultados de salud en pacientes con enfermedad pulmonar obstructiva crónica (EPOC). Objetivos. Evaluar si la hipoxemia nocturna que puede producirse en fumadores con o sin EPOC, con o sin apnea obstructiva del sueño (AOS) o con EPOC y AOS, puede estar asociada con EAP. Métodos. Se analizaron los datos transversales de dos cohortes prospectivas que incluyeron a 284 fumadores reclutados en contexto de un programa de cribado de cáncer de pulmón o consulta de neumología general y que en la visita inicial completaron TAC y poligrafía de sueño ambulatoria. En la TAC se midió el diámetro del tronco de la arteria pulmonar (dAP) y la relación del dAP con el diámetro de la raíz de la arteria aorta (dAP/dAo). Se definió la presencia de EAP en casos de dAP ≥ 29 mm en hombres y ≥ 27 mm en mujeres. Para ambos sexos, también se definió EAP si el dAP/dAo era > 0.9. La asociación de EAP con las características basales se estimó mediante modelos de regresión logística multivariable. Resultados. La prevalencia de EAP determinada por la medición del dAP o por la relación dAP/dAo fue de 27% y 11.6% respectivamente. El dAP se relacionó de forma independiente con la obesidad, definida como un índice de masa corporal ≥ 30 kg/m2 (OR 2.01; 95%CI 1.06–3.78), un menor volumen espiratorio forzado en el primer segundo (FEV1) (OR 1.03; 95%CI 1.02–1.05) y un mayor nivel de hipoxemia nocturna calculada como % de tiempo del registro de sueño con una SaO2 < 90% (T90) (OR 1.02; 95%CI 1.00–1.03). Solo el T90 fue una variable independiente asociada a EAP, cuando ésta se definió por la relación dAP/dAo (OR 1,02; 95%CI 1,01–1,03). Excluyendo a los sujetos con AOS, los análisis demuestran que solo T90 se mantiene como una variable determinante de EAP tanto definida por el dAP (OR 1.02; 95%CI 1.01–1.03) como definida por la relación dAP/dAo (OR 1.04; 95%CI 1.01–1.07). Conclusiones: En fumadores con o sin EPOC, la hipoxemia nocturna se asocia con EAP independientemente de la coexistencia de AOS.Background: Pulmonary artery enlargement (PAE) detected using chest computed tomography (CT) is associated with poor outcomes in chronic obstructive pulmonary disease (COPD). Aim. To assess whether nocturnal hypoxemia occurring in smokers, with or without COPD, obstructive sleep apnea (OSA) or their overlap, may be associated with PAE assessed by chest CT. Methods. We analyzed data from two prospective cohort studies that enrolled 284 smokers from a lung cancer screening program or general pulmonology consult including baseline home sleep apnea studies and chest CT scans. Main pulmonary artery diameter (PAD) and the ratio of the PAD to that of the aorta (PA:Ao ratio) were measured. PAE was defined as a PAD ≥ 29 mm in men and ≥ 27 mm in women or as a PA:Ao ratio > 0.9. We evaluated the association of PAE with baseline characteristics using multivariable logistic models. Results: PAE prevalence was 27% as defined by PAD measurements and 11.6% by the PA:Ao ratio. A body mass index ≥ 30 kg/m2 (OR 2.01; 95%CI 1.06–3.78), lower % predicted of forced expiratory volume in one second (FEV1) (OR 1.03; 95%CI 1.02– 1.05) and higher % of sleep time with O2 saturation < 90% (T90) (OR 1.02; 95%CI 1.00–1.03), were associated with PAE as determined by PAD. However, only T90 remained significantly associated with PAE as defined by the PA:Ao ratio (OR 1.02; 95%CI 1.01–1.03). In the subset group without OSA, only T90 remains associated with PAE, whether defined by PAD measurement (OR 1.02; 95%CI 1.01–1.03) or PA:Ao ratio (OR 1.04; 95%CI 1.01–1.07). Conclusions: In smokers with or without COPD, nocturnal hypoxemia was associated with PAE independently of OSA coexistence

Hipoxemia nocturna y diámetro de arteria pulmonar en fumadores con/sin Enfermedad Pulmonar Obstructiva Crónica

Antecedentes: El ensanchamiento anormal de la arteria pulmonar (EAP) detectado mediante tomografía axial computarizada de tórax (TAC) está asociado con peores resultados de salud en pacientes con enfermedad pulmonar obstructiva crónica (EPOC). Objetivos. Evaluar si la hipoxemia nocturna que puede producirse en fumadores con o sin EPOC, con o sin apnea obstructiva del sueño (AOS) o con EPOC y AOS, puede estar asociada con EAP. Métodos. Se analizaron los datos transversales de dos cohortes prospectivas que incluyeron a 284 fumadores reclutados en contexto de un programa de cribado de cáncer de pulmón o consulta de neumología general y que en la visita inicial completaron TAC y poligrafía de sueño ambulatoria. En la TAC se midió el diámetro del tronco de la arteria pulmonar (dAP) y la relación del dAP con el diámetro de la raíz de la arteria aorta (dAP/dAo). Se definió la presencia de EAP en casos de dAP ≥ 29 mm en hombres y ≥ 27 mm en mujeres. Para ambos sexos, también se definió EAP si el dAP/dAo era > 0.9. La asociación de EAP con las características basales se estimó mediante modelos de regresión logística multivariable. Resultados. La prevalencia de EAP determinada por la medición del dAP o por la relación dAP/dAo fue de 27% y 11.6% respectivamente. El dAP se relacionó de forma independiente con la obesidad, definida como un índice de masa corporal ≥ 30 kg/m2 (OR 2.01; 95%CI 1.06–3.78), un menor volumen espiratorio forzado en el primer segundo (FEV1) (OR 1.03; 95%CI 1.02–1.05) y un mayor nivel de hipoxemia nocturna calculada como % de tiempo del registro de sueño con una SaO2 < 90% (T90) (OR 1.02; 95%CI 1.00–1.03). Solo el T90 fue una variable independiente asociada a EAP, cuando ésta se definió por la relación dAP/dAo (OR 1,02; 95%CI 1,01–1,03). Excluyendo a los sujetos con AOS, los análisis demuestran que solo T90 se mantiene como una variable determinante de EAP tanto definida por el dAP (OR 1.02; 95%CI 1.01–1.03) como definida por la relación dAP/dAo (OR 1.04; 95%CI 1.01–1.07). Conclusiones: En fumadores con o sin EPOC, la hipoxemia nocturna se asocia con EAP independientemente de la coexistencia de AOS.Background: Pulmonary artery enlargement (PAE) detected using chest computed tomography (CT) is associated with poor outcomes in chronic obstructive pulmonary disease (COPD). Aim. To assess whether nocturnal hypoxemia occurring in smokers, with or without COPD, obstructive sleep apnea (OSA) or their overlap, may be associated with PAE assessed by chest CT. Methods. We analyzed data from two prospective cohort studies that enrolled 284 smokers from a lung cancer screening program or general pulmonology consult including baseline home sleep apnea studies and chest CT scans. Main pulmonary artery diameter (PAD) and the ratio of the PAD to that of the aorta (PA:Ao ratio) were measured. PAE was defined as a PAD ≥ 29 mm in men and ≥ 27 mm in women or as a PA:Ao ratio > 0.9. We evaluated the association of PAE with baseline characteristics using multivariable logistic models. Results: PAE prevalence was 27% as defined by PAD measurements and 11.6% by the PA:Ao ratio. A body mass index ≥ 30 kg/m2 (OR 2.01; 95%CI 1.06–3.78), lower % predicted of forced expiratory volume in one second (FEV1) (OR 1.03; 95%CI 1.02– 1.05) and higher % of sleep time with O2 saturation < 90% (T90) (OR 1.02; 95%CI 1.00–1.03), were associated with PAE as determined by PAD. However, only T90 remained significantly associated with PAE as defined by the PA:Ao ratio (OR 1.02; 95%CI 1.01–1.03). In the subset group without OSA, only T90 remains associated with PAE, whether defined by PAD measurement (OR 1.02; 95%CI 1.01–1.03) or PA:Ao ratio (OR 1.04; 95%CI 1.01–1.07). Conclusions: In smokers with or without COPD, nocturnal hypoxemia was associated with PAE independently of OSA coexistence

Obesity as an adipose tissue dysfunction disease and a risk factor for infections – Covid-19 as a case study

Severe Acute Respiratory Syndrome Coronavirus 2 (SARS CoV2) disease (COVID-19) is a novel threat that hampers life expectancy especially in obese individuals. Though this association is clinically relevant, the underlying mechanisms are not fully elucidated. SARS CoV2 enters host cells via the Angiotensin Converting Enzyme 2 receptor, that is also expressed in adipose tissue. Moreover, adipose tissue is also a source of many proinflammatory mediators and adipokines that might enhance the characteristic COVID-19 cytokine storm due to a chronic low-grade inflammatory preconditioning. Further obesity-dependent thoracic mechanical constraints may also incise negatively into the prognosis of obese subjects with COVID-19. This review summarizes the current body of knowledge on the obesity-dependent circumstances triggering an increased risk for COVID-19 severity, and their clinical relevanc

Chest CT-assessed comorbidities and all-cause mortality risk in COPD patients in the BODE cohort

Abstract Background and objective: The availability of chest computed tomography (CT) imaging can help diagnose comorbidities associated with chronic obstructive pulmonary disease (COPD). Their systematic identification and relationship with allcause mortality have not been explored. Furthermore, whether their CT-detected prevalence differs from clinical diagnosis is unknown. Methods: The prevalence of 10 CT-assessed comorbidities was retrospectively determined at baseline in 379 patients (71% men) with mild to severe COPD attending pulmonary clinics. Anthropometrics, smoking history, dyspnoea, lung function, exercise capacity, BODE (BMI, Obstruction, Dyspnoea and Exercise capacity) index and exacerbations rate were recorded. The prevalence of CT-determined comorbidities was compared with that recorded clinically. Over a median of 78 months of observation, the independent association with all-cause mortality was analysed. A ‘CT-comorbidome’ graphically expressed the strength of their association with mortality risk. Results: Coronary artery calcification, emphysema and bronchiectasis were the most prevalent comorbidities (79.8%, 62.7% and 33.9%, respectively). All were underdiagnosed before CT. Coronary artery calcium (hazard ratio [HR] 2.09; 95% CI 1.03–4.26, p = 0.042), bronchiectasis (HR 2.12; 95% CI 1.05–4.26, p = 0.036) and low psoas muscle density (HR 2.61; 95% CI 1.23–5.57, p = 0.010) were independently associated with all-cause mortality and helped define the ‘CT-comorbidome’. Conclusion: This study of COPD patients shows that systematic detection of 10 CT-diagnosed comorbidities, most of which were not detected clinically, provides information of potential use to patients and clinicians caring for them

Nocturnal Hypoxemia and CT Determined Pulmonary Artery Enlargement in Smokers

Background: Pulmonary artery enlargement (PAE) detected using chest computed tomography (CT) is associated with poor outcomes in chronic obstructive pulmonary disease (COPD). It is unknown whether nocturnal hypoxemia occurring in smokers, with or without COPD, obstructive sleep apnoea (OSA) or their overlap, may be associated with PAE assessed by chest CT. Methods: We analysed data from two prospective cohort studies that enrolled 284 smokers in lung cancer screening programs and completing baseline home sleep studies and chest CT scans. Main pulmonary artery diameter (PAD) and the ratio of the PAD to that of the aorta (PA:Ao ratio) were measured. PAE was defined as a PAD ≥ 29 mm in men and ≥27 mm in women or as a PA:Ao ratio > 0.9. We evaluated the association of PAE with baseline characteristics using multivariate logistic models. Results: PAE prevalence was 27% as defined by PAD measurements and 11.6% by the PA:Ao ratio. A body mass index ≥ 30 kg/m2 (OR 2.01; 95%CI 1.06–3.78), lower % predicted of forced expiratory volume in one second (FEV1) (OR 1.03; 95%CI 1.02–1.05) and higher % of sleep time with O2 saturation < 90% (T90) (OR 1.02; 95%CI 1.00–1.03), were associated with PAE as determined by PAD. However, only T90 remained significantly associated with PAE as defined by the PA:Ao ratio (OR 1.02; 95%CI 1.01–1.03). In the subset group without OSA, only T90 remains associated with PAE, whether defined by PAD measurement (OR 1.02; 95%CI 1.01–1.03) or PA:Ao ratio (OR 1.04; 95%CI 1.01–1.07). Conclusions: In smokers with or without COPD, nocturnal hypoxemia was associated with PAE independently of OSA coexistence

Nocturnal Hypoxemia and CT Determined Pulmonary Artery Enlargement in Smokers

Background: Pulmonary artery enlargement (PAE) detected using chest computed tomography (CT) is associated with poor outcomes in chronic obstructive pulmonary disease (COPD). It is unknown whether nocturnal hypoxemia occurring in smokers, with or without COPD, obstructive sleep apnoea (OSA) or their overlap, may be associated with PAE assessed by chest CT. Methods: We analysed data from two prospective cohort studies that enrolled 284 smokers in lung cancer screening programs and completing baseline home sleep studies and chest CT scans. Main pulmonary artery diameter (PAD) and the ratio of the PAD to that of the aorta (PA:Ao ratio) were measured. PAE was defined as a PAD ≥ 29 mm in men and ≥27 mm in women or as a PA:Ao ratio &gt; 0.9. We evaluated the association of PAE with baseline characteristics using multivariate logistic models. Results: PAE prevalence was 27% as defined by PAD measurements and 11.6% by the PA:Ao ratio. A body mass index ≥ 30 kg/m2 (OR 2.01; 95%CI 1.06–3.78), lower % predicted of forced expiratory volume in one second (FEV1) (OR 1.03; 95%CI 1.02–1.05) and higher % of sleep time with O2 saturation &lt; 90% (T90) (OR 1.02; 95%CI 1.00–1.03), were associated with PAE as determined by PAD. However, only T90 remained significantly associated with PAE as defined by the PA:Ao ratio (OR 1.02; 95%CI 1.01–1.03). In the subset group without OSA, only T90 remains associated with PAE, whether defined by PAD measurement (OR 1.02; 95%CI 1.01–1.03) or PA:Ao ratio (OR 1.04; 95%CI 1.01–1.07). Conclusions: In smokers with or without COPD, nocturnal hypoxemia was associated with PAE independently of OSA coexistence