Overcoming
underdiagnosis:
identifying
patients with
overlap syndrome
Insider insights on how to identify and treat overlap
syndrome to help you get patients healthy at home.
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As if managing chronic obstructive pulmonary disease (COPD) isn’t complex enough, it is commonly linked with several comorbidities.¹ Treating these diseases together poses critical challenges in reducing symptoms, exacerbations, and, therefore, readmissions.² But treating these comorbid conditions is only half the battle. Because their symptoms and risk factors often overlap, COPD care teams often struggle with the initial step of identifying them.³ This raises the risk of serious comorbidities going undiagnosed and treatment failing to address them. To help care teams navigate these issues, we’ve tapped into Professor of Medicine and Chief Medical Liaison Teofilo Lee-Chiong. Read on to learn his insider insights on how to identify comorbidities to get patients healthy at home.
Overlap syndrome: COPD and OSA
One of the most common diseases that overlaps with COPD is obstructive sleep apnea (OSA).⁴ While there is no known causal relationship between these diseases, their negative effects can be far more severe when they occur together.¹⁻³ The co-occurrence of these diseases is therefore referred to as overlap syndrome.¹⁻⁴ Let’s take a closer look.
Contributors
Obstructive sleep apnea
Overlap syndrome
Nocturnal desaturations that result in increased systemic and pulmonary blood pressure2
More severe nocturnal hypoxemia, hypoventilation, pulmonary hypertension, comorbid obesity, and diabetes5
Data you can’t ignore
The 3 major needs in overcoming underdiagnosis
Need #1: Diagnostic discipline
A fundamental step to improving health outcomes is early and accurate diagnosis. Yet for comorbid respiratory diseases, this is easier said than done. Key challenges include:
- -OSA symptoms could be confused as effects of COPD
- -Onset could be slow, which can impact awareness³
- -Urgent symptoms are typically found during sleep⁶
While diagnostic tools are available, best practices for using them are often unclear. Consider these suggestions in choosing your diagnostic approach.
COPD: spirometry¹
OSA: oximetry and patient questionnaire (such as STOP BANG questionnaire, Epworth Sleepiness scale, and Berlin questionnaire)⁶
Insider insight: The diagnostic doers
“Don’t leave diagnoses to chance. If you have patients who smoke or are obese, test them for respiratory comorbidities.”
Teofilo Lee-Chiong, MD Professor of Medicine, National Jewish Health Professor of Medicine, University of Colorado Chief Medical Liaison, Philips Respironics
Need #2: Protocols
Very few clinics have established protocols for screening and managing comorbidities in COPD patients. Dr. Lee-Chiong explains, “Each clinic approaches care management based on what’s perceived to be important to them and their patient population.” Overlooking evidence-based care is a significant barrier to driving progress.
Here are 3 examples from Dr. Lee-Chiong:
-
1) Monitoring:
COPD patients should be tested for nighttime oxygen levels if daytime levels are low. This should be repeated over time—and urgency to do so increases dramatically in those with more advanced or unstable disease.
-
2) Follow-up:
When care teams engage patients about their health status over time, they are in a better position to maintain wellness and support readmission reduction. ACOs are leading the way by investing significantly in personal follow-ups at home. -
3) Thinking beyond the primary condition:
While heart disease impacts millions of patients, clinicians are not commonly seeing them as potential indicators of respiratory diseases. Patients deserve a protocol to ensure this opportunity is never missed.
Many of these protocols take time and resources to put into practice. But Dr. Lee-Chiong reinforces the urgency of doing so—and offers this simple tip to get started:
Many of these protocols
take time and resources
to put into practice. But
Dr. Lee-Chiong reinforces
the urgency of doing so—
and offers this simple tip
to get started:
Taking the first step to creating treatment protocols is as easy as adding questions to EMR records. Asking whether the patient snores or is obese can shed light on evidence that can make all the difference.”
Teofilo Lee-Chiong, MD Professor of Medicine, National Jewish Health Professor of Medicine, University of Colorado Chief Medical Liaison, Philips Respironics
Need #3: Best practice champions
COPD care teams always put their patients first. However, they often don’t have a true advocate for informing and enforcing best practices—and this can limit care quality.
On behalf of patients, Dr. Lee-Chiong urges care teams to find and promote best practice champions. He believes that they are able to redefine value in key ways, including:
“These are complex matters. We need champions—those who care deeply about improving lives and are willing to rally various groups to work together to assure better care for everyone.”
Teofilo Lee-Chiong, MD Professor of Medicine, National Jewish Health Professor of Medicine, University of Colorado Chief Medical Liaison, Philips Respironics
Treating overlap syndrome
Treating—or not treating—OSA in patients with overlap syndrome has been proven to impact clinical outcomes.⁸ Yet with the many complexities in identifying overlap syndrome come many complexities in treating it. Here’s our insider info on how to effectively manage these patients to help move wellness forward.
Beyond oxygen therapy
Oxygen therapy alone has not been shown to improve outcomes. In fact, use of supplemental oxygen has been connected with an increase in duration of apneic episodes and the development of hypercapnia.⁹ Continuous positive airway pressure (CPAP) is the preferred treatment for OSA and has been shown to improve outcomes in patients with overlap syndrome.²
Pharmacologic treatment
No studies have been conducted to evaluate the effects of pharmacologic treatment in patients with overlap syndrome. Use of these treatments should therefore be determined based on data in each disease alone. Unfortunately, no data have been established on the role of pharmacologic treatment for OSA.
Data you can’t ignore
Here's our insider guide on using pharmocologic treatment for COPD, with respect to sleep issues:
Comorbid conditions associated with COPD—like OSA—can dramatically raise the risk of poor health, exacerbations, and admissions.²,⁷ Fortunately, you have the tools to end the cycle of underdiagnosis and spot comorbid conditions earlier and more accurately. This can help you deliver higher quality care from the start and raise expectations for long-term wellness.¹
*Dr.Lee-Chiong is a Philips Respironics employee.
References:
1. Marin JM, Carrizo SJ. Overlap Syndromes of Sleep and Breathing Disorders. In: Kryger MH, Roth T, Dement WC, eds. Principles and Practice of Sleep Medicine. 6 ed. Philadelphia: Elsevier; 2017:1179–1188.e5. 2. Pruitt B. A deadly duo: when COPD and OSA overlap. RT for Decision Makers in Respiratory Care. May 2014. 3. Balachandran JS, Masa JF, Mokhlesi B. Obesity hypoventilation syndrome epidemiology and diagnosis. Sleep Med Clin. 2014;9(3):341–347. 4. Berry RB. Sleep Related Breathing Disorders Classification. In: Kryger MH, Roth T, Dement WC, eds. Principles and Practice of Sleep Medicine. 6th ed. Phiadelphia, PA: Elsevier; 2017:1030–1040.e3. 5. Greenberg H, Lakticova V, Scharf SM. Obstructive Sleep Apnea. In: Kryger MH, Roth T, Dement WC, eds. Principles and Practice of Sleep Medicine. 6th ed. Philadelphia, PA: Elsevier; 2017:1110–1124.e6. 6. Chung F, Abdullah HR, Liao P. STOP-Bang questionnaire: a practical approach to screen for obstructive sleep apnea. Chest. 2016;149(3):631–638. 7. 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(3):325–331. 8. Marin JM, Carrizo SJ. Overlap Syndromes of Sleep and Breathing Disorders. In: Kryger M, Roth T, Dement WC, eds. Principles and Practice of Sleep Medicine. 6th ed. Philadelphia, PA: Elsevier; 2017:1179-1189. 9. Patil SP, Winocur E, Buenaver L, Smith MT. Medical and Device Treatment for Obstructive Sleep Apnea: Alternative, Adjunctive, and Complementary Therapies. In: Kryger M, Roth T, Dement WC, eds. Principles and Practice of Sleep Medicine. 6th ed. Philadelphia, PA: Elsevier; 2017:1138-1153.
