Citation:
Nokes B, Raza H, Malhotra A. Pulmonary hypertension and obstructive sleep apnea. J Clin Sleep Med. 2020;16(4):649.
We thank Simonson et al1 for raising awareness about the issue of pulmonary hemodynamics and sleep-disordered breathing in patients with systemic sclerosis.2 Regarding the link between sleep-disordered breathing and pulmonary hypertension, Sajkov et al3 showed that pulmonary hypertension associated with obstructive sleep apnea is generally mild to moderate, reversible with positive airway pressure therapy, and often associated with marked hypoxic vasoreactivity (ie, major elevations in pulmonary artery pressure with hypoxic exposure). In the case of fibrotic lung disease, including that which can occur in scleroderma, pulmonary artery pressures may be elevated by hypoxic pulmonary vasoconstriction as well as destruction of lung parenchyma. Pulmonary artery dilation does not necessarily correspond with elevated pulmonary artery pressures, but dilation has been associated with sleep-disordered breathing.1,4 The association between sleep-disordered breathing and pulmonary artery dilation was further noted in our study in individuals with systemic sclerosis.2
In the case of parenchymal lung disease, specifically chronic obstructive pulmonary disease (COPD), a prominent paper in New England Journal of Medicine suggested that pulmonary artery dilation may be predictive of COPD exacerbation.4 We wonder whether sleep-disordered breathing may be important causally in this association, particularly in light of recent evidence showing reduced risk of rehospitalizations by giving positive airway pressure to patients with frequent exacerbations of COPD.5 We also note that the definitions of pulmonary hypertension have recently changed (ie, mean pulmonary artery pressure of 20 mm Hg rather than 25 mm Hg), suggesting that older studies may have underestimated the true burden of pulmonary hypertension. Thus, we are highly supportive of further efforts to characterize the links between pulmonary hypertension, pulmonary artery dilation, and sleep-disordered breathing, particularly in patients with parenchymal lung disease. Further study could assess important mechanisms as well as the impact of positive airway pressure on cardiopulmonary physiology as well as other health outcomes.
DISCLOSURE STATEMENT
All authors have seen and approved of this manuscript. All authors have reported no financial conflicts of interest. ResMed provided a philanthropic donation to UC San Diego. The authors report no conflicts of interest.
REFERENCES
- 1.Simonson J, Greenberg H, Talwar A. Pulmonary artery dilation and obstructive sleep apnea. J Clin Sleep Med. 2020;16(4):647. doi: 10.5664/jcsm.8300. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2.Nokes BT, Raza HA, Cartin-Ceba R, et al. Individuals with scleroderma may have increased risk of sleep-disordered breathing. J Clin Sleep Med. 2019;15(11):1665–1669. doi: 10.5664/jcsm.8036. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Sajkov D, Wang T, Saunders NA, Bune AJ, McEvoy RD. Continuous positive airway pressure treatment improves pulmonary hemodynamics in patients with obstructive sleep apnea. Am J Respir Crit Care Med. 2002;165(2):152–158. doi: 10.1164/ajrccm.165.2.2010092. [DOI] [PubMed] [Google Scholar]
- 4.Wells JM, Washko GR, Han MK, et al. Pulmonary arterial enlargement and acute exacerbations of COPD. N Engl J Med. 2012;367(10):913–921. doi: 10.1056/NEJMoa1203830. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Murphy PB, Rehal S, Arbane G, et al. Effect of home noninvasive ventilation with oxygen therapy vs oxygen therapy alone on hospital readmission or death after an acute COPD exacerbation: a randomized clinical trial. JAMA. 2017;317(21):2177–2186. doi: 10.1001/jama.2017.4451. [DOI] [PMC free article] [PubMed] [Google Scholar]