If I can get off of nasal steroids, would I be able to eventually get off my BiPAP?

I have been reading more about how nasal and oral steroid use has been linked to a higher incidence of OSA. I have been on all of these for at least 10 years and have been on BiPAP for about 5 years. If I can get off of these steroids, would I be able to eventually get off my BiPAP?  

The question posed is whether or not long-term use of nasal and oral steroids in the treatment of an unnamed condition [presumably chronic pulmonary disease] could worsen sleep apnea, and if so, could elimination of steroids improve sleep apnea such that an individual on BPAP could cease use of the PAP device?

The study referred to by this questioner was conducted with a very precise research protocol. And, even though the number of patients evaluated was small, we would still expect to see some noteworthy changes for the hypothesis tested, assuming it was a sound hypothesis. Based on the introduction in the paper, at minimum, the high co-morbidity rates for asthmatics with sleep apnea patients warrant investigation. And, the chronic use of corticosteroids (oral inhalers, oral medications) in many asthmatics certainly raises suspicions for adverse impact on the upper airway.

Notwithstanding, the primary hypothesis of the study (the expectation that steroids would worsen upper airway collapsibility) “proved” the exact opposite to the prediction. That is, there was a statistically significant decrease in collapsibility for the group as a whole. These findings were accounted for by 8 patients with improvement in the airway, 8 patients showing no change, and only 2 patients showing worsening. These findings by themselves would suggest if anything that treatment with corticosteroids in asthmatic patients might improve sleep-disordered breathing in nearly 50% of patients with co-morbid OSA.

Then again, two additional hypotheses were tested. In some patients tongue strength increased, which is a finding seen in OSA patients, but apparently this change in the tongue had no effect on airway collapsibility in this sample. And, in 3 of 18 patients, MRI scans showed increased fat content around upper airway structures, again with no change in collapsibility of the airway.

In sum, it is very clear this study does not prove a direct link between corticosteroid use and the development of sleep apnea. Thus, nothing from this study could guide someone if he or she chose to decrease corticosteroids with the aim of no longer requiring PAP therapy.

On the other hand, the question that might be more clinically relevant in the case of the questioner is how well each of the current comorbidities is being managed. For example, if this patient’s chronic pulmonary condition has reached a stage of a “COPD” diagnosis, then it would be most important to learn whether the OSA is effectively managed with BPAP. Depending upon the potential severity of the COPD, we would almost always test such a patient on an ABPAP, ASV, ASVAuto, or IVAPS device at our center, because an individual with this complexity would usually respond more favorably to one of these devices than to standard CPAP or BPAP.

Another interesting angle for this patient would be the impact of an effective PAP response on lung function. This point has been studied in asthma, and there is strong speculation that more effective treatment of OSA yields more effective control of asthma in some patients.(1)

Taken together, if someone has been using chronic steroids for a pulmonary condition for a decade, I would make the assumption that the severity level of the disorder must be high and/or the capacity to control the condition (eg, asthma) is low. Thus, I would presume the main issue in play is what makes for the best control of the asthma with or without steroids? If improving the OSA treatment would assist in controlling the asthma, then further exploration of a more advanced PAP technology might be in order. Still, none of the above steps can predict whether or not the patient might continue to need steroids to optimize results.

1. Prasad B, Nyenhuis SM, Weaver TE. Obstructive sleep apnea and asthma: associations and treatment implications. Sleep Med Rev. 2014 Apr;18(2):165-71. doi: 10.1016/j.smrv.2013.04.004. Epub 2013 Jul 23. Review


Barry Krakow MD

Author

Dr Krakow’s 27 years of sleep research have focused on the complex relationship between physiological and psychological sleep disorders. Dr Krakow currently operates private sleep medical center, Maimonides Sleep Arts & Sciences, Ltd., and serves as Classic SleepCare’s paid Medical Director.



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