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Overlap syndrome: an indication for sleep studies?

A pilot study

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The coexistence of obstructive sleep apnea (OSA) and chronic obstructive pulmonary diseases (COPD) is known as overlap syndrome (OS); it occurs in 10–20% of patients with OSA. Patients with OS have a higher risk of pulmonary hypertension and worse nocturnal hypoxemia than those with either disease alone. Differences may be seen according to severity of COPD, anthropometric measures, and polysomnography (PSG) features of patients. Recent studies have suggested that long-term use of continuous positive airway pressure for OSA is associated with worsening of coexistent COPD. This stresses the importance of identifying this subgroup of patients in order to provide adequate therapy.


This study aims to describe the presence of OS among subjects at our institution and study its association to daytime hypercapnia, nocturnal hypoxemia, and severity of OSA and of COPD.


We reviewed the records of patients who underwent PSG and pulmonary function test (PFT) at our center since 2002. Data gathered from PSG and PFTs included respiratory disturbance index (RDI), apnea index, lowest nocturnal desaturation, forced expiratory volume in 1 s (FEV1), FEV1/forced vital capacity ratio, arterial blood gasses, and anthropometric measures.


Five hundred forty-seven records were reviewed, but only 73 met all inclusion criteria for analysis. Thirty-six patients had COPD, 52 had OSA, and 29 had OS. The mean predicted FEV1 percent of all subjects was 80%, and the mean diurnal partial pressure of carbon dioxide (pCO2) was 39 mmHg. There were no significant differences in average pCO2 or RDI between subjects with OSA and OS. In all subjects, hypercapnia significantly correlated with worse RDI (p = 0.01) and with worse nocturnal desaturation (p = 0.01). During rapid eye movement (REM) sleep, those with FEV1 less than 80% predicted had higher RDI than those with higher FEV1 (p = 0.010).


In these preliminary results, the prevalence of OS in our population is similar to that previously reported. Daytime hypercapnia correlated with the more severe sleep-disordered breathing (SDB) and worse nocturnal hypoxemia in all subjects. Severity of obstructive ventilatory impairment is associated with worse SDB during REM sleep. Randomized trials to determine if PSGs are indicated in all patients with severe COPD should be considered. This is an ongoing study.

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Supported by Sociedad De Investigación Cientifica (SODEINC), PO BOX 33060, Veterans Plaza Station, San Juan, PR 00933-0060

Conflict of interest

No affiliations with organizations with financial interest and no conflicts of interest were involved in this study.

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Correspondence to William Rodríguez-Cintrón.

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López-Acevedo, M.N., Torres-Palacios, A., Elena Ocasio-Tascón, M. et al. Overlap syndrome: an indication for sleep studies?. Sleep Breath 13, 409–413 (2009). https://doi.org/10.1007/s11325-009-0263-5

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  • Obstructive sleep apnea (OSA)
  • Overlap syndrome (OS)
  • Chronic obstructive pulmonary diseases (COPD)
  • Polysomnogram (PSG)
  • Hypercapnia