سبحان من لا تطيب الدنيا الا بذكره ... ولا الاخرة الا بعفوه... ولا الجنة الا برؤية وجهه الكريم

1. سبحان من لا تطيب الدنيا الا بذكره ...ولا الاخرة الا بعفوه...ولا الجنة الا برؤية وجهه الكريم

2. Is There any Link between OSAS& ASTHMA? Dr. AliaëAbd-Rabou Mohamed-Hussein European Respiratory Society Scientific Committee Editor in World Journal of Respirology Professor of Pulmonology, Chest Department Assiut University Hospitals, Assiut, Egypt

3. Size of the problems 6-8% of US population 4-6% of US population

4. CAN ASTHMA….. AFFECT SLEEP ???

5. Patients with asthma appear to have an increased risk for OSA • Large epidemiologic studies demonstrate that asthma patients • More frequently report snoring. • OSA symptoms are highly prevalent in clinic-based populations of well-characterized asthma patients.

6. Also….patients with asthma has "Nocturnal" awakening

7. Mechanisms of nocturnalawakening “asthma” Probable: Circadian features airway inflammation melatonin Possible: Airways cooling Supine posture Allergic Factors Gastroesophageal reflux Snoring or Sleep Apnea Sutherland, (2005)

9. Patients with good controlreport less frequent and less severe sleep disturbances compared to uncontrolled subjects.

10. Conversely, sleep per se could …worsen asthma

11. HOW ????

12. Normal subject PEFR 8% Asthmatic subjects 50%

13. Catterall et al,(1989) found that • Airway resistance in asthmatic patients to be approximately double that in non-asthmatics at the start of the nocturnal recording period • and the magnitude of the overnightrise was much greater in asthmatics.

14. Aim: To determine whether a high OSA risk is associated to uncontrolled asthma Sleep Disorders Questionnaire (SA-SDQ) Asthma Control Questionnaire. (ACQ)

15. Multivariate Logistic Regression Models of Not-Well-Controlled Asthma on High OSA Risk, with Adjustmentfor Factors Known To Worsen Asthma Control OSA is a potential contributor to overall asthma control and indipendent ot the other known contributors to asthma control

16. OR 3.4 Eur Respir J 2005; 26: 812–818

17. The National Asthma Education and Prevention Program Expert Panel Report recommends evaluating for OSA as a potential contributor to poor asthma control.

18. In short, OSA and Asthma may have a bidirectional relationship in which each can exacerbate the other.

19. What are the links?

21. Mechanisms linking asthma, and sleep apnea CORE

22. The coexistence and hypothetical link between • Cough/asthma, • Obesity/OSA, • Rhinosinusitis, • and Esophageal reflux could be referred to as the “CORE” syndrome. • In asthmatic patients’ refractory to therapy, CORE components must be considered in the management..

23. 1st component “CORE” Obesity

24. Increased incidence of asthma in overweighed and obese subjects Beuther DA, Sutherland ER: Overweight, Obesity, and Incident Asthma: A Meta-analysis of Prospective Epidemiologic Studies. AJRCCM 2007;175:661-666.

25. Obesity and Asthma (Mediators) Beuther DA et al. Pulmonary Perspectives: Obesity and Asthma. Am J Respir Crit Care Med. 2006;174:112-9

27. Obesity and OSAS JOE The Posthumous Papers of the Pickwick Club- 1836 Charles Dickens

28. OBESITY IS……. • Strongest risk factor for OSA • Present in > 60% of patients referred for a diagnostic sleep evaluation • Wisconsin Sleep Cohort Study • A one standard deviation difference in BMI was associated with a 4-fold increase in disease prevalence

29. OBESITY IS……. A cause of 1- Increased parapharyngeal fat deposition neck circumference: > 17” males > 16” females With subsequent:  smaller upper airway  increase the collapsibility of the pharyngeal airway

30. OBESITY……. 2. Changes in neural compensatory mechanisms that maintain airway patency:  diminished protective reflexes

31. Obesity……… 3. ↑ waist circumference  ↓functional residual capacity which can lead to loss of caudal traction on the upper airway  low lung volumes are associated with diminished oxygen stores

32. 2nd component “CORE” ASTHMA OSAS

33. Eosinofphil IL-5 Basophil Mast cell degranlulation United Airways Disease Allergic Rhinitis... Allergen Challenge Loss of Filter ability Allergen Post nasal drip nose-bronchial reflex Stem cell Cytokine Bone marrow Viral ifection Eosinophil ICAM-1 VCAM-1 Allergen bronchial challenge Bronchial Asthma

34. Allergic rhinitis…. • Nasal obstruction contributes to snoring, sleep-disordered breathing in predisposed individuals. Scharf and Cohen (1997)

36. 3rd component “CORE”

37. GERD…. • GERD is a common condition that affects approximately 20–30% of the adult population. • Several studies have reported an increased prevalence of GERDin patients with OSA. (Spechler, 1992) and (Petersen et al, 1995)

38. GERD….. • Acid reflux into the airway enhances Vagal activity can trigger asthma in some individuals as well as with symptoms of OSAS. Gislason Janson Vermeire et al, (2002)

39. 4th component ….”CORE”(Cardiac)

40. Sleep Disorders and CV diseases

41. OSA is associated with significant cardiovascular morbidities as: • Left ventricular dysfunction, • Arrhythmias, • Myocardial infarction, • and Systemic hypertension.

42. Cardiovascular complications of OSA and how they may relate to asthma ?? Adapted from (Kasasbeh et al, 2007)

43. 5th Component ( Inflammation) A S T H M A OSAS

44. Multiple Pro-Inflammatory Factors in Allergic Asthma & Rhinitis Affect Sleep and OSAS Symptoms Adapted from Ferguson. Otolaryngol Head Neck Surg. 2004;130:617.

46. Treatment modalities

47. Prospective Clinical Studies Reporting the Impact of Treatment With CPAP on Asthma Outcome in Patients With Concomitant OSAS Ann Allergy Asthma Immunol. 2008;101:350–357.

48. Beneficial effects of CPAP in patients with asthma and OSAS “LOCAL” ↑end-expiratory lung volume ↑ expiratory muscle function ↓respiratory rate and dyspnea ↓OSAS induce vagal stimulation ↓OSAS induced increased intrathoracic pressure • ↑mean airway pressure • Recruits underventilated alveoli • ↑minute ventilation, • ↓airways resistance • Stabilizes upper aireways • Prevents peripheral airways closure

49. Beneficial effects of CPAP in patients with asthma and OSAS “ SYSTEMIC”

50. Impact of asthma treatment on sleep