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Sleep related breathing disorders in patients with pulmonary hypertension

Silvia Ulrich, MD, ulris@bluewin.ch, Pulmonary Division, Dep. of Internal Medicine, University Hospital Zurich, Switzerland; Manuel Fischler, MD, manuel.fischler@usz.ch, Dep. of Internal Medicine, University Hospital Zurich, Switzerland; Rudolf Speich, MD, FCCP, rudolf.speich@usz.ch, Dep. of Internal Medicine, University Hospital Zurich, Switzerland; Konrad E. Bloch, MD, FCCP, pneubloc@usz.uzh.ch, Pulmonary Division, Dep. of Internal Medicine, University Hospital Zurich, and Zurich Centre for Integrative Human Physiology, Switzerland

Abstract

Background: Cheyne-Stokes respiration and central sleep apnea (CSR/CSA) are common in patients with left heart failure. We investigated the hypothesis that sleep disordered breathing is also prevalent in patients with right ventricular dysfunction due to pulmonary hypertension.

Methods: We studied 38 outpatients (median; quartiles) age 61 (51;72) years) with pulmonary arterial hypertension (n=23) or thromboembolic pulmonary hypertension (n=15). NYHA class was 2-4, the 6 minute walk distance was 481 (429;550) m. In-laboratory polysomnography (n=22) and ambulatory cardio-respiratory sleep studies (n=38) including pulse oximetry were performed. Quality of life and sleepiness by Epworth score were assessed.

Results: The apnea/hypopnea index was 8 (4;19) events/h with 8 (4;17) central and 0 (0;0.3) obstructive events/h. Seventeen patients (45%) had 10 apnea/hypopnea events/h. Comparison of 13 patients with ³10 CSR/CSA events/h with 21 patients with <10 CSR/CSA events/h (excluding 4 patients with ³10 obstructive events/h from this analysis) revealed no difference in regard to hemodynamics, NYHA class and Epworth sleepiness scores. However patients with ³10 CSR/CSA events/h had a reduced quality of life in the physical domains. Ambulatory cardio-respiratory sleep studies accurately predicted ³10 apnea/hypopnea/h during polysomnography in patients who underwent both studies (area under the receiver operating characteristic curve 0.93, SE ±0.06 p=0.002). The corresponding value for pulse oximetry was 0.63±0.14 (p=ns).

Conclusions: In patients with pulmonary hypertension CSR/CSA is common but obstructive sleep apnea also occurs. Sleep related breathing disorders are not associated with excessive sleepiness but affect quality of life. They should be evaluated by polysomnography or cardio-respiratory sleep studies since pulse oximetry may fail to detect significant sleep apnea.

Key Words: Cheyne stokes respiration • periodic breathing • sleep apnea • pulmonary hypertension • pulmonary arterial hypertension • chronic thromboembolic pulmonary arterial hypertension • pulse oximetry • quality of life • polysomnography • diagnosis