Skip to main content
Log in

Overlap Syndrome

  • Sleeping and Breathing (T Lee-Chiong, Section Editor)
  • Published:
Current Pulmonology Reports Aims and scope Submit manuscript

Abstract

Purpose of Review

This paper aims to critically evaluate recent literature on the epidemiology, pathophysiology, and management of overlap syndrome (OS).

Recent Findings

The prevalence of OS is much higher in patients with either chronic obstructive pulmonary disease (COPD) or obstructive sleep apnea (OSA) (8.1%–65.9%) than in the general population (1–2%). Maladaptive neural, inflammatory, cardiovascular, and autonomic responses are intensified with the coexistence of both conditions, leading to worse diurnal and nocturnal respiratory function. Careful analysis of the oximetry and capnography findings during polysomnography can detect concomitant sleep-related hypoxemia/hypoventilation. Observational studies report salutary effects of CPAP on gas exchange, COPD exacerbation, sexual dysfunction, and mortality.

Summary

COPD or OSA patients should be routinely screened for the presence of OS, since CPAP therapy can improve clinical outcomes. Future studies should investigate the pathophysiological interactions resulting from combined risk factors (smoking and obesity), the impact of oxygen on clinical outcomes, and the role of other positive airway pressure modalities.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: ••Of major importance

  1. Flenley DC. Sleep in chronic obstructive lung disease. Clin Chest Med. 1985;6:651–61.

    CAS  PubMed  Google Scholar 

  2. Young T, Palta M, Dempsey J, Skatrud J, Weber S, Badr S. The occurrence of sleep-disordered breathing among middle-aged adults. New Engl J Med. 1993;328:1230–5.

    CAS  PubMed  Google Scholar 

  3. Peppard PE, Young T, Barnet JH, Palta M, Hagen EW, Hla KM. Increased prevalence of sleep-disordered breathing in adults. Am J Epidemiol. 2013;177:1006–14.

    PubMed  PubMed Central  Google Scholar 

  4. Flegal KM, Kruszon-Moran D, Carroll MD, Fryar CD, Ogden CL. Trends in obesity among adults in the United States, 2005 to 2014. JAMA. 2016;315:2284–91.

    CAS  PubMed  Google Scholar 

  5. Doney B, Hnizdo E, Dillon CF, et al. Prevalence of airflow obstruction in U.S. adults aged 40-79 years: NHANES data 1988–1994 and 2007–2010. COPD. 2015;12:355–65.

    PubMed  Google Scholar 

  6. Jamal A, Homa DM, O'Connor E, et al. Current cigarette smoking among adults—United States, 2005-2014. MMWR Morb Mortal Wkly Rep. 2015;64:1233–40.

    PubMed  Google Scholar 

  7. Bednarek M, Plywaczewski R, Jonczak L, Zielinski J. There is no relationship between chronic obstructive pulmonary disease and obstructive sleep apnea syndrome: a population study. Respiration. 2005;72:142–9.

    PubMed  Google Scholar 

  8. Ganga HV, Nair SU, Puppala VK, Miller WL. Risk of new-onset atrial fibrillation in elderly patients with the overlap syndrome: a retrospective cohort study. J Geriatr Cardiol. 2013;10:129–34.

    PubMed  PubMed Central  Google Scholar 

  9. •• Stanchina ML, Welicky LM, Donat W, Lee D, Corrao W, Malhotra A. Impact of CPAP use and age on mortality in patients with combined COPD and obstructive sleep apnea: the overlap syndrome. J Clin Sleep Med. 2013;9:767–72. This observational study not only corroborated the mortality benefit associated with CPAP therapy but also demonstrated the dose-response relationship between CPAP adherence and survival in patients with overlap syndrome

    PubMed  PubMed Central  Google Scholar 

  10. Basoglu OK, Gunduz C, Tasbakan MS. Prevalence of overlap syndrome in chronic obstructive pulmonary disease patients without sleep apnea symptoms. Clin Resp J. 2016 May 5. [Epub ahed of print]

  11. Hang LW, Hsu JY, Chang CJ, et al. Predictive factors warrant screening for obstructive sleep apnea in COPD: a Taiwan National Survey. Int J Chron Obstruct Pulmon Dis. 2016;11:665–73.

    PubMed  PubMed Central  Google Scholar 

  12. Mermigkis C, Kopanakis A, Foldvary-Schaefer N, et al. Health-related quality of life in patients with obstructive sleep apnoea and chronic obstructive pulmonary disease (overlap syndrome). Int J Clin Pract. 2007;61:207–11.

    CAS  PubMed  Google Scholar 

  13. Perimenis P, Karkoulias K, Konstantinopoulos A, et al. The impact of long-term conventional treatment for overlap syndrome (obstructive sleep apnea and chronic obstructive pulmonary disease) on concurrent erectile dysfunction. Respir Med. 2007;101:210–6.

    PubMed  Google Scholar 

  14. Soler X, Gaio E, Powell FL, et al. High prevalence of obstructive sleep apnea in patients with moderate to severe chronic obstructive pulmonary disease. Ann Am Thorac Soc. 2015;12:1219–25.

    PubMed  PubMed Central  Google Scholar 

  15. •• Steveling EH, Clarenbach CF, Miedinger D, et al. Predictors of the overlap syndrome and its association with comorbidities in patients with chronic obstructive pulmonary disease. Respiration. 2014;88:451–7. This epidemiologic study identified BMI and history of smoking, hypertension, and diabetes as predictors of comorbid OSA in patients with COPD

    PubMed  Google Scholar 

  16. Turcani P, Skrickova J, Pavlik T, Janousova E, Orban M. The prevalence of obstructive sleep apnea in patients hospitalized for COPD exacerbation. B Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2015;159:422–8.

    Google Scholar 

  17. Venkateswaran S, Tee A. Overlap syndrome between chronic obstructive pulmonary disease and obstructive sleep apnoea in a Southeast Asian teaching hospital. Singap Med J. 2014;55:488–92.

    Google Scholar 

  18. Wang Y, Hu K, Liu K, et al. Obstructive sleep apnea exacerbates airway inflammation in patients with chronic obstructive pulmonary disease. Sleep Med. 2015;16:1123–30.

    CAS  PubMed  Google Scholar 

  19. Lacedonia D, Carpagnano GE, Aliani M, et al. Daytime PaO2 in OSAS, COPD and the combination of the two (overlap syndrome). Respir Med. 2013;107:310–6.

    CAS  PubMed  Google Scholar 

  20. Lopez-Acevedo MN, Torres-Palacios A, Elena Ocasio-Tascon M, Campos-Santiago Z, Rodriguez-Cintron W. Overlap syndrome: an indication for sleep studies?: a pilot study. Sleep Breath. 2009;13:409–13.

    PubMed  Google Scholar 

  21. Marin JM, Soriano JB, Carrizo SJ, Boldova A, Celli BR. Outcomes in patients with chronic obstructive pulmonary disease and obstructive sleep apnea: the overlap syndrome. Am J Respir Crit Care Med. 2010;182:325–31.

    PubMed  Google Scholar 

  22. Matsumoto T, Murase K, Tachikawa R, et al. Microalbuminuria in patients with obstructive sleep apnea-chronic obstructive pulmonary disease overlap syndrome. Ann Am Thorac Soc. 2016;13:917–25.

    PubMed  Google Scholar 

  23. Resta O, Foschino Barbaro MP, Bonfitto P, et al. Hypercapnia in obstructive sleep apnoea syndrome. Neth J Med. 2000;56:215–22.

    CAS  PubMed  Google Scholar 

  24. Rizzi M, Palma P, Andreoli A, et al. Prevalence and clinical feature of the “overlap syndrome”, obstructive sleep apnea (OSA) and chronic obstructive pulmonary disease (COPD), in OSA population. Sleep Breath. 1997;2:68–72.

    CAS  PubMed  Google Scholar 

  25. Shiina K, Tomiyama H, Takata Y, et al. Overlap syndrome: additive effects of COPD on the cardiovascular damages in patients with OSA. Respir Med. 2012;106:1335–41.

    PubMed  Google Scholar 

  26. Resta O, Foschino Barbaro MP, Brindicci C, Nocerino MC, Caratozzolo G, Carbonara M. Hypercapnia in overlap syndrome: possible determinant factors. Sleep Breath. 2002;6:11–8.

    PubMed  Google Scholar 

  27. Sharma B, Neilan TG, Kwong RY, et al. Evaluation of right ventricular remodeling using cardiac magnetic resonance imaging in co-existent chronic obstructive pulmonary disease and obstructive sleep apnea. COPD. 2013;10:4–10.

    PubMed  Google Scholar 

  28. Radwan L, Maszczyk Z, Koziorowski A, et al. Control of breathing in obstructive sleep apnoea and in patients with the overlap syndrome. Eur Respir J. 1995;8:542–5.

    CAS  PubMed  Google Scholar 

  29. Jordan AS, White DP, Fogel RB. Recent advances in understanding the pathogenesis of obstructive sleep apnea. Curr Opin Pulm Med. 2003;9:459–64.

    PubMed  Google Scholar 

  30. Verbraecken J, McNicholas WT. Respiratory mechanics and ventilatory control in overlap syndrome and obesity hypoventilation. Respir Res. 2013;14:132.

    PubMed  PubMed Central  Google Scholar 

  31. Barnes PJ. Cellular and molecular mechanisms of chronic obstructive pulmonary disease. Clin Chest Med. 2014;35:71–86.

    PubMed  Google Scholar 

  32. Unnikrishnan D, Jun J, Polotsky V. Inflammation in sleep apnea: an update. Rev Endocr Metab Disord. 2015;16:25–34.

    CAS  PubMed  PubMed Central  Google Scholar 

  33. Hawrylkiewicz I, Sliwinski P, Gorecka D, Plywaczewski R, Zielinski J. Pulmonary haemodynamics in patients with OSAS or an overlap syndrome. Monaldi Arch Chest Dis. 2004;61:148–52.

    CAS  PubMed  Google Scholar 

  34. Taranto-Montemurro L, Messineo L, Perger E, et al. Cardiac sympathetic hyperactivity in patients with chronic obstructive pulmonary disease and obstructive sleep apnea. COPD. 2016:1–6.

  35. Huang H, Yao L. Analysis of airway resistance and hypoxemia in overlap syndrome. Saudi Med J. 2016;37:758–61.

    PubMed  PubMed Central  Google Scholar 

  36. Taranto-Montemurro L, Messineo L, Perger E, et al. Cardiac sympathetic hyperactivity in patients with chronic obstructive pulmonary disease and obstructive sleep apnea. COPD. 2016;13:706–11.

    PubMed  Google Scholar 

  37. Regan EA, Hokanson JE, Murphy JR, et al. Genetic epidemiology of COPD (COPDGene) study design. COPD. 2010;7:32–43.

    PubMed  Google Scholar 

  38. Krachman SL, Tiwari R, Vega ME, et al. Effect of emphysema severity on the apnea-hypopnea index in smokers with obstructive sleep apnea. Ann Am Thorac Soc. 2016;13:1129–35.

    PubMed  PubMed Central  Google Scholar 

  39. Van de Graaff WB. Thoracic influence on upper airway patency. J Appl Physiol (1985). 1988;65:2124–31.

    CAS  Google Scholar 

  40. Squier SB, Patil SP, Schneider H, Kirkness JP, Smith PL, Schwartz AR. Effect of end-expiratory lung volume on upper airway collapsibility in sleeping men and women. J Appl Physiol (1985). 2010;109:977–85.

    Google Scholar 

  41. Hillman DR, Walsh JH, Maddison KJ, Platt PR, Schwartz AR, Eastwood PR, et al. J Appl Physiol (1985). 2013;115:337–45.

    Google Scholar 

  42. Proietti M, Laroche C, Drozd M, et al. Impact of chronic obstructive pulmonary disease on prognosis in atrial fibrillation: a report from the EURObservational Research Programme Pilot Survey on Atrial Fibrillation (EORP-AF) general registry. Am Heart J. 2016;181:83–91.

    PubMed  Google Scholar 

  43. van den Berg ME, Stricker BH, Brusselle GG, Lahousse L. Chronic obstructive pulmonary disease and sudden cardiac death: a systematic review. Trends Cardiovasc Med. 2016;26:606–13.

    PubMed  Google Scholar 

  44. Caples SM, Somers VK. Sleep-disordered breathing and atrial fibrillation. Prog Cardiovasc Dis. 2009;51:411–5.

    PubMed  PubMed Central  Google Scholar 

  45. Raghuram A, Clay R, Kumbam A, Tereshchenko LG, Khan A. A systematic review of the association between obstructive sleep apnea and ventricular arrhythmias. J Clin Sleep Med. 2014;10:1155–60.

    PubMed  PubMed Central  Google Scholar 

  46. Faria AC, da Costa CH, Rufino R. Sleep Apnea Clinical Score, Berlin Questionnaire, or Epworth Sleepiness Scale: which is the best obstructive sleep apnea predictor in patients with COPD? Int J Gen Med. 2015;8:275–81.

    PubMed  PubMed Central  Google Scholar 

  47. Bingol Z, Pihtili A, Cagatay P, Okumus G, Kiyan E. Clinical predictors of obesity hypoventilation syndrome in obese subjects with obstructive sleep apnea. Respir Care. 2015;60:666–72.

    PubMed  Google Scholar 

  48. Balachandran JS, Masa JF, Mokhlesi B. Obesity hypoventilation syndrome epidemiology and diagnosis. Sleep Med Clin. 2014;9:341–7.

    PubMed  PubMed Central  Google Scholar 

  49. Epstein LJ, Kristo D, Strollo Jr PJ, et al. Clinical guideline for the evaluation, management and long-term care of obstructive sleep apnea in adults. J Clin Sleep Med. 2009;5:263–76.

    PubMed  Google Scholar 

  50. Rezaeetalab F, Rezaeitalab F, Dehestani V. Inhaled steroids reduce apnea-hypopnea index in overlap syndrome. Pneumologia. 2013;62:212–4.

    PubMed  Google Scholar 

  51. Nowinski A, Bielen P, Jonczak L, Sliwinski P. Influence of treatment with continuous positive airway pressure on respiratory muscle function and physical fitness in patients with obstructive sleep apnoea and overlap syndrome. Pneumonol Alergol Pol. 2007;75:46–56.

    PubMed  Google Scholar 

  52. O’Brien A, Whitman K. Lack of benefit of continuous positive airway pressure on lung function in patients with overlap syndrome. Lung. 2005;183:389–404.

    PubMed  Google Scholar 

  53. Konikkara J, Tavella R, Willes L, Kavuru M, Sharma S. Early recognition of obstructive sleep apnea in patients hospitalized with COPD exacerbation is associated with reduced readmission. Hosp Pract (1995). 2016;44:41–7.

    Google Scholar 

  54. Liu L, Kang R, Zhao S, et al. Sexual dysfunction in patients with obstructive sleep apnea: a systematic review and meta-analysis. J Sex Med. 2015;12:1992–2003.

    PubMed  Google Scholar 

  55. Cao S, Gan Y, Dong X, Liu J, Lu Z. Association of quantity and duration of smoking with erectile dysfunction: a dose-response meta-analysis. J Sex Med. 2014;11:2376–84.

    PubMed  Google Scholar 

  56. Steinke E, Palm Johansen P, Fridlund B, Brostrom A. Determinants of sexual dysfunction and interventions for patients with obstructive sleep apnoea: a systematic review. Int J Clin Pract. 2016;70:5–19.

    CAS  PubMed  Google Scholar 

  57. Roizenblatt S, Guilleminault C, Poyares D, Cintra F, Kauati A, Tufik S. A double-blind, placebo-controlled, crossover study of sildenafil in obstructive sleep apnea. Arch Intern Med. 2006;166:1763–7.

    CAS  PubMed  Google Scholar 

  58. Neves C, Tufik S, Monteiro MA, Chediek F, Jose FF, Roizenblatt S. The effect of sildenafil on sleep respiratory parameters and heart rate variability in obstructive sleep apnea. Sleep Med. 2010;11:545–51.

    PubMed  Google Scholar 

  59. •• Jaoude P, Kufel T, El-Solh AA. Survival benefit of CPAP favors hypercapnic patients with the overlap syndrome. Lung. 2014;192:251–8. This cohort study on the effects of CPAP on mortality identifies the hypercapnic subgroup of overlap syndrome patients as the main beneficiaries from this therapy

    PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Joseph Roland D. Espiritu.

Ethics declarations

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Conflict of Interest

Joseph Espiritu declares no conflict of interest.

Additional information

This article is part of the Topical Collection on Sleeping and Breathing

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Espiritu, J.R.D. Overlap Syndrome. Curr Pulmonol Rep 6, 102–112 (2017). https://doi.org/10.1007/s13665-017-0172-1

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s13665-017-0172-1

Keywords

Navigation