At least 1 in 10 US residents are inflicted with sleep apnea—or at least, the broad definition of sleep apnea.

2018 CHEST Annual Meeting in San Antonio, TX

, Barbara Phillips, MD, MPH, FCCP, of the University of Kentucky College of Medicine, sat down to discuss the prevalence of the condition in the US. Unfortunately, the patient population is large, diverse, and differing in symptoms and clinical characteristics. As a former president of CHEST, Phillips expressed disappointment with the minimal clinical development towards answering a critical question: what is sleep apnea?

A conservative estimate would be about 10%. The problem with answering that question is—wait for it: we still don't know what sleep apnea is. One of the most interesting sessions that I went to at CHEST was about the phenotypes of obstructive sleep apnea, and what that means is there are all different kinds of people who are diagnosed with sleep apnea.

There's little kids with big tonsils; they're skinny old ladies that have droopy soft palates, so the back of their throat closes off; there's a stereotypic big, heavy middle-aged man; there's the Chinese individual who has a short mandible or short lower jaw. And all of those people could be diagnosed with sleep apnea in a sleep laboratory. But it's becoming increasingly clear that not all of those people are at the same risk for bad things to happen.

I have to say that I'm a little discouraged after this meeting, because we still don't know what sleep apnea is, and we still don't know who will benefit from treatment. We have yet to demonstrate in a randomized controlled trial that treating sleep apnea with CPAP reduces death rates, car crashes, cardiovascular risk, or anything else. And I think the reason for that is because we are not identifying sleep apnea correctly, and we don't know how. And that's what this talk was all about.

It's increasingly clear that the apnea plus hypopnea index—which is the number of times you stop breathing (an apnea) or struggle to breathe (a hypopnea) per hour of sleep&mdash;is a simplistic, overused, not very replicable measure that doesn't predict much of anything. So when you try to identify people, ‘Well, we'll just say that everybody with an apnea plus hypopnea index of over 15 has sleep apnea,’ in that group, you're getting people who don't have sleep apnea.

Click here to sign up for more MD Magazine content and updates.

Barbara Phillips, MD, MPH, FCCP: The Lack of Specialist Inclusion in Sleep Apnea

Gender Differences Discovered in Emerging OSA Phenotype

Joshua Denson, MD, MS: Comorbidities Associated with Asthma

Barbara Phillips, MD, MPH, FCCP: The Problem with Sleep Apnea Diagnoses

With sleep apnea affecting about 10% of the US population—and another 10% potentially going undiagnosed, Barbara Phillips, MD, MPH, FCCP, noted&mdash;the patient size is superior to that of other pulmonary conditions, including 

. But the field still struggles to provide comprehensive care and expedient diagnosis to its patients due to a lack of sleep condition knowledge across specialties.

, last week, Phillips explains the lack of clinical interest towards sleep apnea management, the reticence of the sleep field to include outside specialists, and how those 2 elements result in a lingering issue for patients.

 What is the current state of care for sleep apnea?

 There are people who have severe sleep apnea, however you want to define it, however metric you want to use. There are people who have clearly important sleep-disordered breathing, and they are generally identified fairly readily, and they are started on treatment. I think we have enough infrastructures here, in terms of sleep centers and testing devices, to take care of these people. The problem is now that we don't have enough sleep specialists, and it seems like not many other clinicians are very interested in managing sleep apnea.

There are a lot of reasons for that—some of them historical, some of them political, some of them related to insurance, some of them related to who gets sleep apnea&mdash;but the bottom line is there are not enough practitioners of any stripe who are expert in the management of sleep apnea so that once the diagnosis is made, which is the easy part, that patient is followed like any patient with a chronic disease should be, with careful follow-up, feedback, and adjustments as seen necessary.

I would say the current state right now is not very good.

Why may there be a lack of clinical understanding of sleep apnea among specialists in other fields?

To be brutally honest, and somewhat finger-pointing, I would lay some of the responsibility for this at the foot of professional organizations that represent sleep physicians, and has tended to own, corner, and control the market on the diagnosis and management of these patients—excluding others. And that's just not sustainable, because we have a condition here that is far more prevalent than asthma, and we understood a long time ago that pulmonary specialists can't manage every asthma patient.

We need help, from primary care practitioners, even nurse practitioners, to manage that prevalent, deadly disease. And that realization, that understanding, that dissemination of knowledge about sleep apnea to non-sleep specialists hasn't really happened yet. And I think it's a mistake that the field has made, and by that, I mean the sleep field.

Alternative Sleep Apnea System Receives FDA Approval to Market

Airway diseases, such as asthma and chronic obstructive pulmonary disease (COPD), come with their own host of issues and challenges, but added complications due to sleep disorders, like obstructive sleep apnea (OSA), can bring other comorbidities to the table.

, associate professor of medicine at The University of California, Davis, specialist in pulmonary and critical care medicine, spoke with 

to explain the relationship between sleep disorders and airway diseases.

What is the relationship between sleep medicine and airway diseases? 

Zeki: Obstructive [sleep apnea] or central sleep apnea are very prevalent—in particular, OSA. They do overlap in airway diseases. There is some correlation or epistemological data that shows your asthma is much worse if you have OSA that is not being treated.

It is incredibly important to identify sleep apnea in general, let alone in the setting of airway disease where it becomes more important.

What we do in the clinic is, if we have a patient we suspect has sleep apnea, we work them up aggressively and we treat it [the suspected sleep apnea], and we make sure they [patients] are compliant because it makes treating their asthma and COPD—at least anecdotally&mdash;much easier. There is literature to support that as well.

The pathophysiological mechanisms are interesting and ‘probably’—in quotations, because we haven’t worked that out yet&mdash;are related to periods of hypoxemia (when patients are asleep)&mdash;and that can trigger all kinds of inflammatory pathways in the body systemically, let alone in the lung. That may actually make your asthma or COPD worse in the daytime or working hours. That is 1 reasonable hypothesis.

What are the comorbidities associated between sleep disorders and airway diseases? 

The older you are, and if you have COPD or overlap [COPD-asthma overlap], the more likely you are to have cardiovascular comorbidities—hypertension, coronary disease, history of stroke, etc. That aspect seems to correlate more with age, COPD, and overlap [asthma-COPD-overlap]. When we looked at our clinic, we saw the same thing.

If you have OSA, that in and of itself increases your risks for hypertension and potential negative cardiovascular outcomes, like heart failure, sudden death, and things like that. Those comorbidities do go together.

If you just have asthma, it’s less prevalent, but it can be there as well, especially if there is obesity with asthma.

A lot of these comorbidities overlap, but if you have identified patients as having COPD if they’re older, then the risk of cardiovascular comorbidities—at least the prevalence&mdash;is actually higher.

The Relationship Between Sleep Disorders and Airway Diseases

Continuous positive airway pressure (CPAP) is the more than just the first-line treatment for patients with sleep apnea. It’s sometimes their only option. Though dental-based therapies to resolve jaw placement have progressed to the market, not many treatments addressing the primary symptoms of the common condition are in clinical consideration.

That resolves Barbara Phillips, MD, MPH, FCCP, to look elsewhere. Phillips, from the University of Kentucky College of Medicine, sat down with 

 in San Antonio, TX, to share what she learned in sessions focusing on alternative medicines for sleep apnea. More specifically, she discussed the potential of marijuana.

: What is the role of CPAP in sleep apnea treatment?

CPAP is the primary treatment that we have right now for obstructive sleep apnea. I would like to say that there are other treatments, and I think the second most commonly used treatment is the use of a dental device sometimes called a mandibular lower jaw advancement device. It pulls the lower jaw forward to keep the tongue out of the throat so that the patient can breathe and sleep at the same time. And the dental organizations have gotten their act together, and they've produced research that shows that these devices can improve blood pressure, can improve sleepiness overall.

The trend in the literature I've read suggests that they don't improve anything as well as CPAP does—except maybe quality of life, which is important. But they are way better than nothing, they are way better than placebo, and they are way better than any surgical intervention that we've come up with so far.

Are there any potentially new therapies in clinical development?

One of the most interesting sessions that I went to at CHEST was this is “Your Sleep on Drugs” session. I went because I'm disturbed by how many medications are prescribed without much thought about the long-term effects or the addiction potential. I mean, our current

opioid epidemic is an example of this. And there was an entire talk dedicated to marijuana and sleep and, you know, I'm a child of the ‘70s. That's when I was at college, right, so I was interested in this topic and didn't know much about it.

There is some data to suggest that marijuana could improve mild sleep apnea. I was interested in this there is little data about other pharmacologic treatment in general. The positive effect is not robust but it's there, and again, it's better than nothing—which is what a lot of patients are going to get if the only option you give them is a CPAP. Now I'm not recommending that we all go out and recommend that our patients smoke a few joints before bedtime to help their sleep apnea, but that's a promising area.

Barbara Phillips, MD, MPH, FCCP: CPAP, Marijuana for Sleep Apnea

The complications and patient burdens of sleep apnea diagnosis tests have been a continued issue for Barbara Phillips, MD, MPH, FCCP.

At last year’s CHEST Annual Meeting in Toronto, ON, Phillips, of the University of Kentucky School of Medicine, 

 the diagnosis and management of sleep apnea has been “too complicated, too time consuming, too expensive, too patient unfriendly, too test-oriented and not nearly enough follow-up chronic management-oriented.”

 in San Antonio, TX, Phillips got to reiterate her argument. In one particular session, she debated with Nancy A. Collop, MD, of the Emory University Sleep Center, on the merits of the sleep laboratory’s role in patient diagnosis. Phillips recapped the debate with 

, of which the details served as a complement to the comment she had provided just a year earlier.

What are some of the issues with current diagnosing strategies for sleep apnea?

 So, the session that I was involved in as a speaker was a debate, and it was between me and Nancy Collop, who is a past president of the Organized Sleep Medicine Society. And the debate was, I took the ‘pro’ side—which is that people with sleep apnea can bypass the sleep laboratory completely in some cases. And we both agreed that this is not for everyone, but there are now several decent randomized, controlled trials showing that patients who were diagnosed with sleep apnea with a home sleep test&mdash;which costs a fraction of an in-lab study and it's much less intrusive to the person's lifestyle&mdash;and then treated with so-called smart CPAP or auto-titrating CPAP, thus never having to spend a night in the sleep laboratory, do as well, or in a couple of situations, better than people who spend a night or 2 in a sleep laboratory.

Based on that science, I think that bypassing the sleep laboratory ought to be the standard ought to be the standard. And there are exceptions to that rule, just as there are exceptions to everything we do in medicine. It is true that if a patient with heart failure is treated with CPAP, and the CPAP doesn't relieve the apneas, that person is at an increased risk of death and the best and quickest way to find out if a CPAP relieves the apnea is to do that study in the sleep center.

There’s going to always be people who need to go to the sleep center. There are always going to be people that are complicated, or they can't figure out how to do a home study, or you might be worried that they have some other condition that requires monitoring that's more intense. But for the norm, for the standard, garden-variety patient who looks pretty typically to have sleep apnea, I don't think they need to go to the sleep center except to pick up their auto-titrating CPAP machine.

Nancy took the other point of view. I was not convinced.

Her argument centered on mostly complaints about insurance companies, and how they try to dictate who gets what kind of study, and that we don't get all the data that we should when we do a home test on somebody. And she did say clinicians will lose money. Now, I think we'd be better off if we kept our eye on the ball of what's best for patients.

Barbara Phillips, MD, MPH, FCCP: The Diagnosis Debate for Sleep Apnea

While sources differ on whether e-cigarettes are beneficial or inhibitive to tobacco cessation efforts, Jackie Hayes, MD, pulmonary and critical care physician at Brooke Army Medical Center, pointed out that lacking data don’t allow for a real conclusion.

 to explain what data is known about e-cigarettes in relation to tobacco cessation efforts and what data needs to still be acquired.

 What data is the available on e-cigarettes?

The current data on electronic cigarettes, or e-cigarettes, is limited. There are several longitudinal or cohort population studies that have shown mixed results. Some have shown a benefit with some decrease in cessation, but others have not.

Another thing that some of the studies have shown there is a decrease in the number of cigarettes smoked per day with e-cigarettes. Unfortunately, not all studies have shown that outcome. Some studies have been completely negative without any benefit of the use of e-cigarettes.

What I have seen in some more recent studies is that e-cigarettes may actually hinder an individual’s ability to become abstinent form smoking over time.

 What data is currently lacking on e-cigarettes?

Currently, we don’t have a lot of good, randomized control trials. There are a couple that have shown, again, mixed results, but I think in order to get enough data to support the use of electronic cigarettes for tobacco cessation or smoking cessation, we are going to need more randomized control trials that are well-designed and also show a benefit with a reduction in the use of tobacco cigarettes.

I think we need to recruit more individuals who are interested in tobacco cessation—to stop smoking&mdash;and we also need to have more standardized trials, a standardized device, that can be compared to other types of medications for tobacco cessation, such as nicotine replacement therapy, placebo e-cigarettes, or have even pharmacotherapies, such as varenicline or bupropion.

One thing I would like to add on that I am frequently am asked whether or not I would recommend electronic cigarettes as a tobacco cessation aid. I think, right now, my answer, for the most part, would be no.

But, I think if you do have an individual who has failed the traditional methods of tobacco cessation, using FDA -approved medications, electronic cigarettes might be an option for some of those individuals.

I do recommend they be sued with caution because the data is mixed, and we need more data before we can fully recommend electronic cigarettes as a smoking cessation aid.  

E-Cigarettes: What Do We Know?

A wealth of literature on asthma therapies was published in the last year, which showcased the increasing therapeutic treatment options available for patients and the physicians treating them.

However, all of the data can be overwhelming, which is why pulmonologist, Navitha Ramesh, MD, distilled the past year’s data into a literature review on asthma in a presentation while at the 

, Ramesh highlighted the key takeaways her from her presentation.

 What are the main highlights you observed in your review of published literature on asthma?

 A lot has happened in asthma in the last year. It’s a very exciting time for asthma.

The studies that came out in the past year looked at patients with asthma ranging from mild all the way to severe. They answered questions [for physicians] as to ‘What should I do with my mild asthmatic? What should I do with my severe asthmatic?’

I think the studies are all ‘real world’ in sense since they look at patients’ medication adherence. The studies asked questions like ‘Are they going to take these medications?’ I think these studies relate more to the patients.

The first 2 studies I reviewed were SYGMA 1 and 2, where they looked at using inhaled cortical steroid/long-acting beta agonist combinations as needed in patients who have asthma. The traditional thought is asthmatics need to be on inhaled cortical steroids on a routine basis.

But how much is that being followed in the general population? It’s not great.

Consequently, they [investigators] catered to that question and asked, ‘If they used this combination treatment as needed, would it help them have less exacerbations and improve lung function?’ These 2 studies showed that yes, you can use them. They’re noninferior to using inhaled cortical steroids on a routine basis.   

The other interesting part of these 2 studies was that if you use the inhaled cortical steroid and long-acting beta agonists as needed, the dose of the inhaled cortical steroid is much less than the inhaled cortical steroids on a regular basis, which I thought was interesting.

: What does this data mean for physicians and healthcare providers? What should they be implementing in their practices?

 I wouldn’t say it’s ok for patients to be noncompliant— it’s important to stress [medication]  adherence&mdash;but if they have a compelling reason why they cannot use inhaled cortical steroids on a regular basis, such as if they are unable to afford the medications or for some reason they don’t remember to take it twice a day, this is another alternative.

It’s not inferior for the patients to use the inhaled cortical steroids and LABA [long-acting beta agonist] combination inhalers on a regular basis.

The other complimentary thing to this is the FDA [US Food and Drug Administration] just removed the boxed warning for inhaled cortical steroids and long-acting beta agonists.

The background for this is, in 2003, there was a trial that came out called the he Salmeterol Multicenter Asthma Research Trial (SMART) where the basic conclusion was long-acting beta agonist medications increase the mortality in patients with asthma. Hence, everyone was scared to use them.

The FDA mandated the major manufacturers of the long-acting beta agonist medications to do large-scale studies. They had a joint oversight committee to see if the studies were uniform in nature and if they study came out well.

The results came out in just the past year where they said inhaled cortical steroids and was long-acting beta agonists do not increase mortality.

They basically debunked the [increased mortality] theory, and that made the FDA remove the boxed warning in December of last year [2017]. This is all good news for our patients and us.

: Is there any 1 treatment or combination of treatments you would recommend as the go-to treatment, or does it vary on the case of asthma?

 I think asthma is becoming less of a 1-size-fits-all type of a disease. [It is important to] look at each patients and their different phenotypes. More and more is being learned about the pathophysiology of the disease, and recognizing not every patient can be given the same set of treatment is important. We have to cater our treatment based on each patient.

If you have a patient who has very severe asthma and who has symptoms that are uncontrolled, and you exhausted all your inhaler options, there is hope with the new biologic medications that are coming out.

The most recent 1 is the dupilumab, which is anti-IL 4 and anti-IL 13 monoclonal antibody. This medication has shown promise in reducing severe exacerbations in asthma and improving lung function in asthma as well as decreasing the steroid dose in severe asthmatics who are chronically on oral steroids.   

If the FDA does approve dupilumab, it’s a ray of hope for the patients because they do suffer from asthma. They have significant morbidity with asthma, despite doing everything they can, like controlling comorbidities, avoiding triggers, and using inhalers.

This population of severe asthmatics sometimes just don’t improve, and they might have some benefit from dupilumab—that’s my hope.

Navitha Ramesh, MD: Recent & Upcoming Asthma Treatments

The current treatment landscape for chronic obstructive pulmonary disease (COPD) includes long-acting beta2 agonists (LABAs) and long-acting muscarinic antagonists (LAMAs) in combination, as well as inhaled cortical steroids (ICS). However, biologics are also entering clinical trials, which could serve as novel, potential therapies for COPD in the future.

, Nicola Hanania, MD, MS, director of the Airways Clinical Research Center at Baylor College of Medicine, spoke with 

and outlined the ruling on triple therapies and the future of biologics for COPD. 

 How effective are triple therapies for COPD?

 We are starting to learn about fixed-dose triple therapies. Naturally, in our clinic, we often have patients on 2 inhalers—1 containing a LABA/LAMA, the other 1 containing an ICS&mdash;but not on fixed inhalers.

Now, there is emerging data from fixed triple therapies. One is approved in the United States, another is approved in Europe. These agents show, no matter what study you look at, superiority in the subgroup of patients with high exacerbation risks.

Triple therapies have an important role, but maybe [more so] in the more severe patients [and] those with high risk of exacerbation. And, that beneficial role may extend to patients with high blood eosinophils.

It [high blood eosinophils] seems to be a good marker, although there is a big debate [over] what is a good cutoff above which you would start an ICS. People are thinking maybe around 150 cells at baseline would be a good cutoff. Again, I have to mention that nobody has good evidence that this is a good, real cutoff.

 Where is the future of COPD treatment headed?

 Right now, the big push is to look at biologics targeting different inflammatory mediators. We have made quite a bit of achievement in asthma. We have 4 biologics approved—maybe 2 more to come in the next year.

In COPD, we—unfortunately&mdash;don’t have any biologics approved. There is some work being done, and I think that’s a very important target.

There are certain early studies looking at different pathways we can block that may help these patients. Many of these agents being studied are in phase 2 trials though, and so it is too early to tell whether they are going to work or not.

Navitha Ramesh, MD, Reviews Recent & Upcoming Asthma Treatments

Nicola Hanania, MD, MS: Triple Therapies & Biologics in COPD

Biomarkers are a fairly uncharted territory in asthma and chronic obstructive pulmonary disease (COPD), but adding 

) into the mix can make it all the more confusing.

2018 CHEST Annual Meeting in San Antonio, TX,

, associate professor of medicine at The University of California, Davis, specialist in pulmonary and critical care medicine, sat down with 

to go over the known and unknown regarding biomarkers in asthma, COPD, and ACO.

What data is available on biomarkers in asthma, COPD, and ACO?

It’s really an area that needs a tremendous amount of research. There is a lot more to be done, and we have to agree on the definition of a biomarker. What is a biomarker?

Are you measuring something in the blood, in the sputum, is it in the exhaled breath, is it a [computed tomography] CAT scan, is it a lung function parameter? There are a lot of ‘biomarkers.’ Most people are referring to a blood test of course.

Pulmonary diseases are complex though. The problem—or the reality will be&mdash;is some kind of combination of exhaled breath and blood testing that we will put together to enhance diagnostic accuracy. That’s still an area that needs a lot of work.

The best thing I can tell you that I have seen from the literature is if you put together exhaled nitric oxide and blood eosinophil counts, your positive predictive value increases for asthma-COPD overlap relative to COPD—let’s say as an example. There is decent data for that.

There is still much more that needs to be done. Other things that have been reported, like interleukin 6, NGAL [neutrophil gelatinase-associated lipocalin], and others, are still in the realm of research. We don’t have any specific cutoffs to say, ‘Oh, if you’re above this level or below that level, you have asthma or you have COPD.’ That still needs a lot of work and validation.

The first stage is to identify the biomarkers that, on average, can allow you to distinguish between these disorders. The higher-level work is what are the cutoffs, and are they actually predictive? Can these change your diagnostic thinking between those 3 disorders—ACO, COPD, and asthma?

What are the next steps that need to be taken in order to establish biomarkers for asthma, COPD, and ACO?

If you’re talking about asthma and COPD, the answer is easier. However, if you’re talking about asthma, COPD, and ACO overlap, I think the first thing that needs to happen is we need to come up with a consensus [on the] definition for asthma-COPD overlap that everyone agrees on.

Once we agree on that [the definition], then the research will move forward much more rapidly. Right now, we’re still stuck in the realm of taxonomy, classifying, and trying to understand where it fits in.

I think the lowest hanging fruit is to just accept the latest description we have—which is from GINA, the Global Initiative for Asthma&mdash;which is really a description of asthma-COPD overlap. It’s not really a diagnostic criteria, but people have used it. For the time being, if people can agree to use that until we come up with a consensus [on the] definition, then research can move forward in that area as well.

I think it will be still be dubious until we all agree on a definition globally because there is a lot of research coming out from all over the world on overlap. That makes it challenging.

Another way to answer the question is to just take what we’re using in the clinic now—IgE [Immunoglobulin E] levels, testing for atopy, exhaled nitric oxide, peripheral blood eosinophils, etc. Use those tests and follow patients over time to then look back and see if you can correlate it to 1 disease type or another.

It’s not that simple, but these are simple answers to a very complicated question.

The right way to do it is to agree on the definitions and move forward with the proper studies that are longitudinal and that are done periodically so that you can correlate it to the various clinical parameters—lung function when they exacerbate and the various diagnostic criteria.

Amir A. Zeki, MD: Biomarkers in Asthma, COPD & ACO Overlap

Defining and diagnosing idiopathic pulmonary fibrosis (IPF) is of the upmost importance due to the irreversible and progressive decline in lung function caused by the rare pulmonary disease. With recent guideline updates though, disease diagnosis and definition can now be further assisted.

 Tejaswini Kulkarni, MD, MPH, assistant professor, University of Alabama at Birmingham, sat down with 

how acute exacerbations of IPF are defined and diagnosed.

How are acute exacerbations of IPF defined and diagnosed?

Currently, an acute exacerbation of IPF is defined as acute, clinically significant respiratory deterioration that is characterized by evidence of new widespread alveolar abnormalities.

The diagnostic criteria are previous or a current diagnosis of IPF, acute worsening or the development of dyspnea within the past 1-month, computed tomography (CT) scan findings of new bilateral ground-glass opacities, and/or consolidations that are superimposed on a background pattern of usual interstitial pneumonia, and then final the deterioration that is not fully explained by cardiac failure or fluid overload.

These were the diagnostic criteria that were defined in a 2016 paper that talked about acute exacerbations of IPF.

The only difference we saw from 2007, and a very importance difference, was that these new guidelines do not require a clinician to absolutely exclude other causes like infection or other triggers like reflux of aspiration to call it an IPF exacerbation.

Tejaswini Kulkarni, MD, MPH: Defining & Diagnosing Acute Exacerbations of IPF

 are a field of unknowns, but that doesn’t detract from the potential risks and concerns they raise. While some sources claim electronic cigarettes can assist in tobacco cessation, others are weary they may fall into the hands of youth and lead to other tobacco products.

, Jackie Hayes, MD, pulmonary and critical care physician at Brooke Army Medical Center, reiterated some of the concerns associated with electronic cigarettes with 

 in addition to highlighting comorbidities associated with tobacco use.

 Should there be concern for electronic cigarette use in young individuals?

 I think the use of electronic cigarettes by young people is a significant issue. One of the concerns is the safety and the potential harm to young people, but an even bigger concern is their [electronic cigarettes] potential as a gateway device to smoking traditional or tobacco cigarettes.  

We are seeing an increase in the incidence of individuals—young people&mdash;who use electronic cigarettes becoming smokers. So that is 1 concern&mdash;that it may not reduce the overall incidence of the use of tobacco cigarettes. [Another concern is] over time, it may recruit or encourage young people to smoke tobacco cigarettes, and therefore; lead to the risk of illness as they grow older.

Tobacco is 1 of the major killers, major ideologies of multiple illnesses to include—cardiovascular disease and lung disease. I think its contributions to those disorders is quite significant and leads to many patients having an early onset of disease and early mortality. I think those issues are the biggest concerns.

Jackie Hayes, MD: E-Cigarettes in Youth & Tobacco Comorbidities

While precision medicine is gaining momentum across the medical spectrum, its use and application in the field of pulmonology may be especially helpful, such as in airway diseases like asthma, chronic obstructive pulmonary disease (COPD), asthma-COPD overlap (ACO), and emphysema.

Nicola Hanania, MD, MS, director of the Airways Clinical Research Center at Baylor College of Medicine, spoke with 

and described what the landscape of precision medicine looks like in pulmonology, including tools that are needed and the potential benefit they could provide.

What is the landscape of precision medicine in pulmonology?  

: Precision medicine, obviously, is the way to go. It will help us pick the right treatment based on the patient’s genetic, environmental, pharmacogenetic buildup, and the type of disease they have. For many years, we thought asthma and COPD are just, both of which, constitute a one-size-fit-all type of disease, but that’s not the case.

To better understand how 1 drug would work best in 1 patient compared to another, we really need to know mechanisms or endotypes. We are still at the seashore; we don’t have all the tools to do so—tools meaning biomarkers.

In asthma, we have few biomarkers that help us—blood eosinophils, sputum eosinophils, exhaled nitric oxide may be a good predictor as a biomarker, and serum IgE can help is identify the allergic phenotype.

In COPD, we actually are much further behind. Currently, maybe blood eosinophils can help us identify those inhaled steroid responders. We have some radiologic biomarkers in COPD. They’re still in the research arena, but they may also help us better identify some patients who may respond best to certain treatments.   

The emphysema studies—such as the valve studies&mdash;may also help us identify those who are the best responders to this type of treatment as not every emphysema patient will respond.

We’re still a ways before we say we concluded all our work, but this is something we are striving to achieve besides therapies for these patients. We need the tools to develop, and we certainly need the studies to help us reach that goal.

Nicola Hanania, MD: Precision Medicine in Pulmonology

Sleep apnea is associated with a host of comorbidities, but its overlap with specific conditions is of high importance and concern for Barbara Phillips, MD, MPH, FCCP.

 in San Antonio, TX, Phillips sat down with 

 and highlighted the main comorbidities associated with sleep apnea, connecting the overlap among asthma, chronic obstructive pulmonary disease (COPD), bronchitis, emphysema, and obesity.

 What are the most common comorbidities associated with sleep apnea? Are other pulmonological conditions common in patients?

As you know, obesity is an important risk factor for sleep apnea. You don’t—I want to say it again&mdash;you don’t have to be heavy for sleep apnea. You could just be old, or genetically predisposed, or have big tonsils, or be Asian, or whatever.

But, obesity is a hugely important and 1 of the few modifiable risk factors for sleep apnea. The comorbidities that go with obesity tend be seen in sleep apnea. By far and away, the 2 most prevalent [comorbidities] are diabetes and hypertension, which are associated, as you know, with obesity.

It turns out though, because your question was specifically, ‘What other pulmonary conditions are associated with sleep apnea?’ that asthma is as well. It turns out that obesity is also a risk factor asthma, and there all kinds of reasons for that—from, simply, the mechanical compression of the lungs and the airways by obesity, to the little things we can’t see that are inflammatory mediators that are secreted by fat tissue.

Asthma tends to be common in people with obstructive sleep apnea, and there is now an emerging body of evidence that says, ‘A patient who has both obstructive sleep apnea and asthma will do better if that person uses CPAP [continuous positive airway pressure].’

COPD, chronic obstructive pulmonary disease, bronchitis, emphysema—we’ll all lump it all together&mdash;COPD, which certainly is a bread and butter pulmonary disease, also has significant overlap with obstructive sleep apnea. In fact, the combination of COPD and sleep apnea is called the overlap syndrome.

There is now pretty good data that has come largely from Spain, showing that if a patient with COPD and sleep apnea uses CPAP, that person is less likely to die—which is kind of an important outcome. Also&mdash;almost equally important to the clinician and even some of the patients is&mdash;that patient is less likely to have a COPD exacerbation.

COPD is a chronic, miserable condition, but the worst part of it for the patients is their exacerbations. When the disease gets so bad, then something has to happen. They have to take an antibiotic, or they have to be admitted to the hospital, or they have to be in the intensive care unit. That is where the misery, and that is where the cost of management of COPD comes in. It may be that each COPD exacerbation also does more, further, acute damage to the lungs and worsen the COPD.

We do see a lot of overlap with COPD and asthma in people with obstructive sleep apnea.

Barbara Phillips: MD, MPH, FCCP: Sleep Apnea Comorbidities

Sleep apnea can be dangerous for anyone, but certain occupations can put individuals at an increased risk for the sleep disorder and its associated comorbidities.

 in San Antonio, TX, Barbara Phillips, MD, MPH, FCCP, spoke with 

 about which occupations tend to be associated with sleep apnea and what criteria may constitute high-risk levels.

 What are some of the professions most commonly associated with sleep apnea? 

That’s a very good question. Again, I have to come back to the phenotypes of sleep apnea. For example, mild rim-related sleep apnea without terrible hypoxemia or falls in low blood oxygen is seen mostly in premenopausal, obese women. So, it would be in whatever profession they’re doing, right?

The typical sleep apnea that people learned about in medical school, if they learned about it at all, is a middle-aged obese man. Of course, [that] is seen in commercial drivers—people in safety-sensitive positions.

There is a huge awareness now in our federal government about the risk that sleep apnea plays for a crash in commercial vehicle drivers and all people in safety sensitive positions.

Again, 1 of our problems is trying to decide what sleep apnea is in this population. What is the cut-point for either you’re treated, or you’re out of a job?

Is it an apnea plus hypopnea index of 5, is it an apnea plus hypopnea index of 20, or is it something that we’re not even measuring or routinely reporting, which I think it probably is. I think it’s probably the time spent what an oxygen level below 90% that really predicts the greatest risk of a person having a crash or any other kind of accident due to inattentiveness.

I think there is an increasing awareness. We are all at risk for sleep apnea, whether we have it or not, because people who are out first responders are people [who] on the road with us, [and they] are afflicted and sometimes not treated.

Barbara Phillips, MD, MPH, FCCP: The Jobs Most Burdened with Sleep Apnea

Choosing the right treatment plan for a new sleep apnea patient can be challenging, but doing so based off of observational data can make the task all the more daunting.

 in San Antonio, TX, Barbara Phillips MD, MPH, FCCP, sat down with 

and explained why choosing the appropriate dose strength and treatment strategy for a new sleep apnea patient can be difficult. While continuous positive airway pressure (CPAP) has been noted to be a beneficial treatment for patients with sleep apnea, Phillips noted the positive results are largely based off of observational and cross-sectional data.

 What is the relationship between pulmonary arterial hypertension and sleep apnea? 

The relationship between pulmonary arterial hypertension and obstructive sleep apnea is not as well described as you would think. To sum it up briefly, it tends to be mild.

Pulmonary hypertension pressure is 30 millimeters or so in the pulmonary arteries. It [pulmonary arterial hypertension] tends to be completely ignored while the clinician managing the patients goes after much sexier and more expensive treatments. It [also] tends to be present in the sickest people—people who have low blood oxygen, [and] not just at night when they’re sleeping, but also when they are awake. That’s a small group [of patients].

 What is the dosing strength and regimen strategy for treating a new sleep apnea patient? 

That is a really good question because of a couple of things. Those 2 things are, as I mentioned before—we can’t promise a patient, on the basis of well-done randomized controlled trials, that using CPAP is going to prevent any terrible thing.

We have a lot of observational data, we have a lot of cross-sectional data, and that data tends to show that people who use CPAP are less likely to die, have a car crash, have a stroke, so forth, and so on. The problem with that kind of observational, cross-sectional data is the people who use CPAP are more likely to quit smoking, take their medicines, exercise, lose weight, and do other things that are going to improve their prognosis. That’s the problem with an observational trial.

Let me give you an example of an observational conclusion. If you went to my YMCA [Young Men's Christian Association], almost any morning, and you were trying to swim laps there, you would find half the pool is filled with people who are doing water aerobics.

CHEST 2018 Perspectives