COPD-OSA overlap syndrome


Overlap syndrome is a term used to describe the coexistence of obstructive sleep apnea (OSA) and COPD, and was first coined by researcher David Flenley when he estimated that this association of two common diseases probably involved many patients.1 Indeed, research has indicated a high prevalence of OSA in COPD patients, including one recent study that shows up to 66% of the COPD patients who enrolled in pulmonary rehabilitation tested positive for OSA.2 Furthermore, patients with overlap syndrome may experience worsening symptoms of COPD.3

Clinical consequences of overlap syndrome

  • Increased incidence of exacerbations3
  • Prolonged oxygen desaturation at night, which can lead to systemic and pulmonary blood pressure increases. This increases the risk of pulmonary hypertension, right heart failure and cor pulmonale4,5 (One study showed the prevalence of pulmonary hypertension in OSA patients was 16% compared to 86% in overlap syndrome patients6)
  • Higher mortality rates compared to those with either COPD or OSA alone7, 8, 9 (One study found mortality rates were seven times higher in the overlap syndrome population10)
  • Higher incidence of mortality at night11
  • Worse reported quality of life12

Treatment for overlap syndrome

Continuous positive airway pressure (CPAP) remains the standard treatment for both OSA and overlap syndrome.13 Research has shown that patients with overlap syndrome who use CPAP therapy have experienced:

  • Improved survival and decreased hospitalizations9
  • Decreased risk of mortality14
  • Increased survival estimates15
  • Improved blood gases and mean pulmonary arterial pressure16
  • Improved PaCO2, PaO2 and FEV1 17

However, as an overlap syndrome patient’s disease progresses, they may develop daytime hypercapnia. CPAP alone may not fully correct hypercapnia or hypoxemia, so non-invasive ventilation (NIV) treatment and/or supplemental oxygen may increase the clinical benefit to the patient.18 NIV therapy can theoretically rest overloaded respiratory muscles, prevent nocturnal hypoventilation, and reset central respiratory drive in patients with hypercapnia.19 NIV devices also include several synchronization features that can prolong expiratory time, which helps to prevent air trapping and may greatly improve patient comfort and compliance.

Learn more about NIV for COPD

Screening your COPD patients for OSA

As studies suggest that patients with overlap syndrome may have a worse prognosis than patients with only one of these diseases, COPD care providers should consider screening all of their COPD patients for obstructive sleep apnea.

There are several tools to help screen these patients during a regularly scheduled appointment. The American Sleep Apnea Association endorses three tests that you can quickly and easily administer and will help you identify your patients most at risk for sleep apnea:

American Thoracic Society/European Respiratory Society guidelines also suggest that those with relatively mild COPD and evidence of pulmonary hypertension should be referred for overnight testing.20


  • 01

    Flenley DC. Sleep in chronic obstructive lung disease. Clin Chest Med, 6 (1985), pp. 51–610

  • 02

    Soler X et al. High prevalence of obstructive sleep apnea in patients with moderate to severe chronic obstructive pulmonary disease. Ann Am Thorac Soc. 2015;12(8):1219-25. dos: 10.1513/AnnalsATS.201407-336OC

  • 03

    Soler-Cataluna JJ et al. Severe acute exacerbations and mortality in patients with chronic obstructive pulmonary disease. Thorax 2005;60(11):925-931.

  • 04

    Trask CH, Cree EM. Oximeter studies on patients with chronic obstructive emphysema, awake and during sleep. N Engl J Med 1962;266:639-642.

  • 05

    Pierce AK et al. Respiratory function during sleep in patients with chronic obstructive lung disease. J Clin Invest 1966; 45 (5):631-636.

  • 06

    Hawrylkiewicz I et al. Pulmonary haemodynamics in patients with OSAS or an overlap syndrome. Monaldi Arch Chest Di. 2004;61(3):148-152

  • 07

    Owens RL and Malhotra A. Sleep-disordered breathing and COPD: The overlap syndrome. Resp Care 2010;55(10): 1333-1346

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    Sanders MH et al. Sleep and sleep-disordered breathing in adults with predominantly mild obstructive airway disease. Am J Respir Crit Care Med 2003;167(1):7–14

  • 09

    Marin JM et al. Outcomes in patients with chronic obstructive pulmonary disease and obstructive sleep apnea: the overlap syndrome Am J Respir Crit Care Med 2010 Aug 1;182(3):325-31. doi: 10.1164/rccm.200912-1869OC. Epub 2010 Apr 8.

  • 10

    Lavie P et al. Mortality in sleep apnea patients: a multivariate analysis of risk factors. Sleep 1995;18(3):149-157

  • 11

    McNicholas WT and Fitzgerald MX. Nocturnal deaths among patients with chronic bronchitis and emphysema. BMJ (Clin Res Ed) 1984; 289(6449):878

  • 12

    Mermigkis C 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(2): 207-211

  • 13

    Owens RL and Malhotra A. Sleep-disordered breathing and COPD: the overlap syndrome. Respir Care 2010;55(10):1333-44

  • 14

    Stanchina ML et al. 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 Aug 15;9(8):767-72. doi: 10.5664/jcsm.2916.

  • 15

    Machado MC et al. CPAP and survival in moderate-to-severe obstructive sleep apnoea syndrome and hypoxaemic COPD. Eur Respir J 2010 Jan;35(1):132-7. doi: 10.1183/09031936.00192008. Epub 2009 Jul 2.

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    Toraldo DM et al. Fixed-pressure nCPAP in patients with obstructive sleep apnea (OSA) syndrome and chronic obstructive pulmonary disease (COPD): a 24-month follow-up study. Sleep Breath 2010 Jun;14(2):115-23. doi: 10.1007/s11325-009-0291-1. Epub 2009 Sep 13.

  • 17

    Mansfield D et al. Effects of continuous positive airway pressure on lung function in patients with chronic obstructive pulmonary disease and sleep disordered breathing. Respirology 1999 Dec;4(4):365-70.

  • 18

    Sampol G et al. Nasal continuous positive airway pressure with supplemental oxygen in coexistent sleep apnoea-hypopnoea syndrome and severe chronic obstructive pulmonary disease. Eur Respir J 1996 Jan; 9(1):111-6

  • 19

    Bhatt SP et al. Noninvasive positive pressure ventilation in subjects with stable COPD: a randomized trial. Int J Chron Obstruct Pulmon Dis 2013; 8: 581–589. Published online 2013 Nov 22. doi: 10.2147/COPD.S53619

  • 20

    Celli BR and MacNee W. Standards for the diagnosis and treatment of patients with COPD: a summary of the ATS/ERS position paper. Eur Respir J 2004;23(6):932–946