LONG-TERM IMPACT OF PULMONARY REHABILITATION ON SLEEP IN COPD PATIENTS AS MEASURED BY ACTIGRAPHY

Abstract

TOPIC: Pulmonary Rehabilitation TYPE: Original Investigations PURPOSE: Chronic obstructive pulmonary disease (COPD) is associated with poor sleep quality. Compared to the general population, COPD patients have delayed sleep initiation, impaired sleep maintenance, increased nightmares, and excessive daytime sleepiness. Poor sleep negatively affects functional capacity, peripheral muscle strength, and health-related quality of life (HRQL), and is associated with increased COPD exacerbations and mortality. Pulmonary rehabilitation (PR) has been shown to improve daytime function, HRQL, and subjective sleep quality in COPD. It has also been shown to improve sleep subjectively but not objectively, as measured by actigraphy in short duration (8-12 weeks). Long-term effects of PR on sleep have not been studied well. We hypothesized that actigraphy would demonstrate subjective and objective improvement in sleep with long-term exercise following completion of PR. METHODS: This was a retrospective study of COPD patients who completed PR at Veteran’s Affairs Loma Linda from 2013 to 2020. Participants underwent 8 weeks of structured PR and 12 months of unstructured exercise program (home and in-center). Actigraphic watch recordings before PR, after 8 weeks of PR, and 12 months after completion of PR were taken. Data were collected on sleep variables, including total time in bed (TBT), total sleep time (TST), sleep onset latency (SOL), sleep efficiency (SE), wakefulness after sleep onset (WASO), and total nocturnal awakenings. Data on spirometry, six-minute walk distance (6MWD), Pittsburgh Sleep Quality Index (PSQI), St. George's Respiratory Questionnaire (SGRQ), and modified Medical Research Council Dyspnea (mMRC) score were also collected. Paired comparisons (t-tests) were performed to assess the impact of PR on sleep variables. RESULTS: Out of 98 participants enrolled for PR during the study period, 16 completed 12-month post-PR assessments including actigraphy and were included in the final analysis. All participants were male with an average age of 72 ± 8 yrs and more than two-thirds (69%) had severe COPD (GOLD stage 3 or 4). Details of subjective and objective sleep outcomes are in the table. There was sustained improvement in 6MWD (mean difference, 68.8m, 95% CI -1.3 to 139, p=0.05) and SGRQ (mean difference, - 8.1 points, 95% CI-16.3 to 0.1, p=0.05), as well as stable mMRC score (mean difference, -0.4 points, -1.2 to 0.5, p=0.37). However, objective sleep variables from actigraphy worsened (TBT, TST) or did not improve (SOL, SE, WASO, Awakenings). PSQI did not improve significantly after 12 months post-PR (mean change, -1.3, 95% CI -3.1 to 0.5, p=0.14). CONCLUSIONS: Pulmonary rehabilitation with an unstructured exercise program after completion of 8 weeks of structured program was not associated with qualitative or quantitative improvements in sleep. Further studies are needed to evaluate whether long-term structured exercise programs following PR could improve sleep in COPD patients. CLINICAL IMPLICATIONS: Sleep is significantly impaired in patients with COPD. Poor sleep can lead to increased cognitive impairment, cardiovascular disease, COPD exacerbations, and mortality. Sleep quality in COPD patients has not been shown to improve after completion of pulmonary rehabilitation. However, long-term structured exercise programs following completion of pulmonary rehabilitation may improve sleep quality in this population. DISCLOSURES: No relevant relationships by Shawn Band Mani Benedict, source=Web Response No relevant relationships by Kathleen Ellstrom, source=Web Response No relevant relationships by Joseph Mak, source=Admin input No relevant relationships by Suman Thapamagar, source=Web Response