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Saulnier L, Prigent H, Hartley S, Delord V, Bossard I, Stalens C, Lofaso F, Leotard A. Sleep disordered breathing assessment in patient with slowly progressive neuromuscular disease. Sleep Med 2024; 114:229-236. [PMID: 38237410 DOI: 10.1016/j.sleep.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 12/18/2023] [Accepted: 01/07/2024] [Indexed: 02/07/2024]
Abstract
BACKGROUND Sleep-disordered breathing (SDB) is common in patients with neuromuscular diseases (NMD). Focusing on hypercapnia may lead to the neglect of other SDB such as obstructive and/or central sleep apnea syndrome (SAS). Our objectives were to assess the risk of inappropriate SDB management according to different screening strategies and to evaluate the prevalence and determinants of isolated and overlapping sleep apnea in patients with slowly progressive NMD. METHODS This monocentric, cross-sectional, retrospective study analyzed medical records of adult NMD patients referred to a sleep department. Diagnostic strategies, including respiratory polygraphy (RP), nocturnal transcutaneous capnography (tcCO2), and blood gases (BG), were assessed for their performance in diagnosing SDB. Demographics and pulmonary function test results were compared between patients with or without SDB to identify predictors. RESULTS Among the 149 patients who underwent a full diagnostic panel (RP + tcCO2 + BG), 109 were diagnosed with SDB. Of these, 33% had isolated SAS, and central apneas were predominant. Using single diagnostic strategies would lead to inappropriate SDB management in two thirds of patients. A combination of 2 diagnostic tools resulted respectively in 21.1, 22.9 and 42.2 % of inappropriate SDB management for RP + tcCO2, RP + BG and tcCO2 + BG. CONCLUSION The significant prevalence of sleep apnea syndrome in patients with slowly progressive NMD highlights the need for increased awareness among clinicians. Improved diagnostics involve a systematic approach addressing both sleep apnea and diurnal and nocturnal alveolar hypoventilation to avoid inappropriate management and limit the consequences of SDB.
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Affiliation(s)
- Lucas Saulnier
- Service de Physiologie et d'Explorations Fonctionnelles, AP-HP, GHU Paris Saclay, Hôpital Raymond Poincaré, Garches, France; Unité de Recherche Clinique Paris Saclay Ouest, AP-HP, Hôpital Raymond Poincaré, Garches, France
| | - Hélène Prigent
- Service de Physiologie et d'Explorations Fonctionnelles, AP-HP, GHU Paris Saclay, Hôpital Raymond Poincaré, Garches, France; « End:icap » U1179 Inserm, UVSQ-Université Paris-Saclay, Versailles, 78000, France
| | - Sarah Hartley
- Service de Physiologie et d'Explorations Fonctionnelles, AP-HP, GHU Paris Saclay, Hôpital Raymond Poincaré, Garches, France
| | | | - Isabelle Bossard
- Centre d'investigation Clinique 1429, AP-HP, Hôpital Raymond Poincaré, Garches, France
| | - Caroline Stalens
- AFM-Téléthon, Direction des Actions Médicales, Evry, 91000, France
| | - Frédéric Lofaso
- Service de Physiologie et d'Explorations Fonctionnelles, AP-HP, GHU Paris Saclay, Hôpital Raymond Poincaré, Garches, France; Université Paris-Saclay, UVSQ, ERPHAN, Versailles, 78000, France
| | - Antoine Leotard
- Service de Physiologie et d'Explorations Fonctionnelles, AP-HP, GHU Paris Saclay, Hôpital Raymond Poincaré, Garches, France; « End:icap » U1179 Inserm, UVSQ-Université Paris-Saclay, Versailles, 78000, France.
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Shah NM, Shrimanker S, Kaltsakas G. Defining obesity hypoventilation syndrome. Breathe (Sheff) 2022; 17:210089. [PMID: 35035556 PMCID: PMC8753617 DOI: 10.1183/20734735.0089-2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 08/24/2021] [Indexed: 01/07/2023] Open
Abstract
With increasing prevalence of obesity, the substantial contribution of obesity hypoventilation syndrome (OHS) to morbidity and mortality is likely to increase. It is therefore crucial that the condition has a clear definition to allow timely identification of patients. OHS was first described as “Pickwickian syndrome” in the 1950s; in subsequent decades, case reports did not clearly delineate between patients suffering from OHS and those suffering from obstructive sleep apnoea. In 1999, the American Academy of Sleep Medicine published a guideline that delineated the cause of daytime hypercapnia as either predominantly upper airway or predominantly hypoventilation. This was the first formal definition of OHS as the presence of daytime alveolar hypoventilation (arterial carbon dioxide tension >45 mmHg) in patients with body mass index >30 kg·m−2 in the absence of other causes of hypoventilation. This definition is reflected in the most recent guidelines published on OHS. Recent developments in defining OHS include proposed classification systems of severity and demonstrating the value of using serum bicarbonate to exclude OHS in patients with a low index of suspicion. Obesity hypoventilation syndrome is defined as daytime alveolar hypoventilation in obese patients in the absence of other causes of hypoventilation. Classifications of severity are now needed to target treatment at the most appropriate individuals.https://bit.ly/3yLuiL9
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Affiliation(s)
- Neeraj M Shah
- Lane Fox Respiratory Service, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Lane Fox Clinical Respiratory Physiology Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Centre for Human and Applied Physiological Sciences (CHAPS), King's College London, London, UK
| | - Sonia Shrimanker
- Lane Fox Respiratory Service, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Lane Fox Clinical Respiratory Physiology Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Georgios Kaltsakas
- Lane Fox Respiratory Service, St Thomas' Hospital, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Lane Fox Clinical Respiratory Physiology Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Centre for Human and Applied Physiological Sciences (CHAPS), King's College London, London, UK
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Rajesh S, Wonderling D, Simonds AK. Obstructive sleep apnoea/hypopnoea syndrome and obesity hyperventilation syndrome in over 16s: summary of NICE guidance. BMJ 2021; 375:n2360. [PMID: 34750147 DOI: 10.1136/bmj.n2360] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Sharangini Rajesh
- National Guideline Centre, Royal College of Physicians, London NW1 4LE, UK
| | - David Wonderling
- National Guideline Centre, Royal College of Physicians, London NW1 4LE, UK
| | - Anita K Simonds
- Royal Brompton and Harefield Hospital, Guys & St Thomas' NHS Foundation Trust, London SW3 6NP, UK
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Dicembrino M, Alejandra Barbieri I, Pereyra C, Leske V. End-tidal CO 2 and transcutaneous CO 2 : Are we ready to replace arterial CO 2 in awake children? Pediatr Pulmonol 2021; 56:486-494. [PMID: 33382537 DOI: 10.1002/ppul.25217] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Revised: 11/27/2020] [Accepted: 11/30/2020] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Arterial blood gas analysis (ABG) is the gold standard test for carbon dioxide measurement. End-tidal PCO2 (PetCO2 ) and transcutaneous PCO2 (PtcCO2 ) are noninvasive alternative methods. OBJECTIVE To examine the use of PetCO2 and PtcCO2 as PaCO2 surrogates in awake children. METHODS A prospective observational study. Consecutive awake children in a stable condition referred to the Sleep Unit of Hospital de Pediatría Dr. J. P. Garrahan with suspected or confirmed sleep-related respiratory disorders requiring ABG were included. PetCO2 and PtcCO2 were recorded simultaneously during arterial puncture. PetCO2 and PtCO2 values were compared with PaCO2 . Correlation coefficient and Bland-Altman analysis were applied. The sample size was calculated considering a mean difference ≤3 mmHg as clinically acceptable. RESULTS Sixty-eight sample sets were obtained from 67 patients. The median age was 9.11 years (0.23-18.76). During 94.1% of the procedures patients breathed spontaneously, 30% needed multiple punctures and 92% resulted in pain. Median (IQR) PaCO2 (mmHg) was 36.3 (31.45; 40.90), PetCO2 33.0 (29; 39) and PtcCO2 38.8 (32.95; 43.32). Correlation and agreement for PaCO2 /PetCO2 and PaCO2 /PtcCO2 was r = .6 and .9, and media of bias = 2.83 (-9.97; 15.64) and -1.88 (-9.01; 5.24), respectively. Hypercapnia (PaCO2 > 45.0 mmHg) was present in 8/68 (11.8%) samples. Sensitivity, specificity, positive predictive value and negative predictive value to detect hypercapnia with PetCO2 was 38%, 98%, 75%, and 92%, respectively, and with PtcCO2 , 100%, 90%, 57%, and 100%, respectively. CONCLUSION PtcCO2 showed better agreement with PaCO2 than PetCO2 but because of the wide dispersion of values, neither method can replace the gold standard. Transcutaneous CO2 might be a good screening tool to detect hypercapnia in awake children.
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Affiliation(s)
- Manuela Dicembrino
- Sleep Unit, Pulmonology Department, Hospital de Pediatría Prof. Dr. J. P. Garrahan, Buenos Aires, Argentina
| | | | - Carla Pereyra
- Pediatrics Department, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Vivian Leske
- Sleep Unit, Pulmonology Department, Hospital de Pediatría Prof. Dr. J. P. Garrahan, Buenos Aires, Argentina
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Predictive Factors for Failure of Noninvasive Ventilation in Adult Intensive Care Unit: A Retrospective Clinical Study. Can Respir J 2020; 2020:1324348. [PMID: 32831978 PMCID: PMC7421696 DOI: 10.1155/2020/1324348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Revised: 06/30/2020] [Accepted: 07/16/2020] [Indexed: 11/18/2022] Open
Abstract
Background Noninvasive ventilation (NIV) has been reported to be beneficial for patients with acute respiratory failure in intensive care unit (ICU); however, factors that influence the clinical outcome of NIV were unclarified. We aim to determine the factors that predict the failure of NIV in critically ill patients with acute respiratory failure (ARF). Setting. Adult mixed ICU in a medical university affiliated hospital. Patients and Methods. A retrospective clinical study using data from critical adult patients with initial NIV admitted to ICU in the period August 2016 to November 2017. Failure of NIV was regarded as patients needing invasive ventilation. Logistic regression was employed to determine the risk factor(s) for NIV, and a predictive model for NIV outcome was set up using risk factors. Results Of 101 included patients, 50 were unsuccessful. Although more than 20 variables were associated with NIV failure, multivariate logistic regression demonstrated that only ideal body weight (IBW) (OR 1.110 (95%1.027-1.201), P=0.009), the maximal heart rate during NIV period (HR-MAX) (OR 1.024 (1.004-1.046), P=0.021), the minimal respiratory rate during NIV period (RR-MIN) (OR 1.198(1.051-1.365), P=0.007), and the highest body temperature during NIV period (T-MAX) (OR 1.838(1.038-3.252), P=0.037) were independent risk factors for NIV failure. We set up a predictive model based on these independent risk factors, whose area under the receiver operating characteristic curve (AUROC) was 0.783 (95% CI: 0.676-0.899, P < 0.001), and the sensitivity and specificity of model were 68.75% and 71.43%, respectively, with the optimal cut-off value of 0.4863. Conclusion IBW, HR-MAX, RR-MIN, and T-MAX were associated with NIV failure in patients with ARF. A predictive model based on the risk factors could help to discriminate patients who are vulnerable to NIV failure.
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American Society for Pain Management Nursing Guidelines on Monitoring for Opioid-Induced Advancing Sedation and Respiratory Depression: Revisions. Pain Manag Nurs 2020; 21:7-25. [DOI: 10.1016/j.pmn.2019.06.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 05/25/2019] [Accepted: 06/14/2019] [Indexed: 01/12/2023]
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Jungquist CR, Chandola V, Spulecki C, Nguyen KV, Crescenzi P, Tekeste D, Sayapaneni PR. Identifying Patients Experiencing Opioid-Induced Respiratory Depression During Recovery From Anesthesia: The Application of Electronic Monitoring Devices. Worldviews Evid Based Nurs 2019; 16:186-194. [PMID: 31050151 DOI: 10.1111/wvn.12362] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Postsurgical patients experiencing opioid-related adverse drug events have 55% longer hospital stays, 47% higher costs associated with their care, 36% increased risk of 30-day readmission, and 3.4 times higher risk of inpatient mortality compared to those with no opioid-related adverse drug events. Most of the adverse events are preventable. GENERAL AIM This study explored three types of electronic monitoring devices (pulse oximetry, capnography, and minute ventilation [MV]) to determine which were more effective at identifying the patient experiencing respiratory compromise and, further, to determine whether algorithms could be developed from the electronic monitoring data to aid in earlier detection of respiratory depression. MATERIALS AND METHODS A study was performed in the postanesthesia care unit (PACU) in an inner city. Sixty patients were recruited in the preoperative admissions department on the day of their surgery. Forty-eight of the 60 patients wore three types of electronic monitoring devices while they were recovering from back, neck, hip, or knee surgery. Machine learning models were used for the analysis. RESULTS Twenty-four of the 48 patients exhibited sustained signs of opioid-induced respiratory depression (OIRD). Although the SpO2 values did not change, end-tidal CO2 levels increased, and MV decreased, representing hypoventilation. A machine learning model was able to predict an OIRD event 10 min before the actual event occurred with 80% accuracy. LINKING EVIDENCE TO ACTION Electronic monitoring devices are currently used as a tool to assess respiratory status using thresholds to distinguish when respiratory depression has occurred. This study introduces a potential paradigm shift from a reactive approach to a proactive approach that would identify a patient at high risk for OIRD. Capnography and MV were found to be effective tools in detecting respiratory compromise in the PACU.
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Affiliation(s)
| | - Varun Chandola
- Department of Computer Science and Engineering, University at Buffalo, Buffalo, NY, USA
| | | | | | | | | | - Phani Ram Sayapaneni
- Department of Computer Science and Engineering, University at Buffalo, Buffalo, NY, USA
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8
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Sunwoo BY. Obesity Hypoventilation: Pathophysiology, Diagnosis, and Treatment. CURRENT PULMONOLOGY REPORTS 2019. [DOI: 10.1007/s13665-019-0223-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Sunwoo BY, Mokhlesi B. Obesity Hypoventilation Syndrome: Will Early Detection and Effective Therapy Improve Long-Term Outcomes? J Clin Sleep Med 2018; 14:1455-1457. [PMID: 30176983 DOI: 10.5664/jcsm.7310] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 08/13/2018] [Indexed: 12/28/2022]
Affiliation(s)
- Bernie Y Sunwoo
- Department of Medicine, Division of Pulmonary and Critical Care, University of California San Diego, San Diego, California
| | - Babak Mokhlesi
- Department of Medicine, Section of Pulmonary and Critical Care, Sleep Disorders Center, The University of Chicago Pritzker School of Medicine, Chicago, Illinois
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Abstract
PURPOSE OF REVIEW This article provides the reader with recent findings on the pathophysiology of comorbidities in the obese, as well as evidence-based treatment options to deal with perioperative respiratory challenges. RECENT FINDINGS Our understanding of obesity-associated asthma, obstructive sleep apnea, and obesity hypoventilation syndrome is still expanding. Routine screening for obstructive sleep apnea using the STOP-Bang score might identify high-risk patients that benefit from perioperative continuous positive airway pressure and close postoperative monitoring. Measures to most effectively support respiratory function during induction of and emergence from anesthesia include optimal patient positioning and use of noninvasive positive pressure ventilation. Appropriate mechanical ventilation settings are under investigation, so that only the use of protective low tidal volumes could be currently recommended. A multimodal approach consisting of adjuvants, as well as regional anesthesia/analgesia techniques reduces the need for systemic opioids and related respiratory complications. SUMMARY Anesthesia of obese patients for nonbariatric surgical procedures requires knowledge of typical comorbidities and their respective treatment options. Apart from cardiovascular diseases associated with the metabolic syndrome, awareness of any pulmonary dysfunction is of paramount. A multimodal analgesia approach may be useful to reduce postoperative pulmonary complications.
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Warricker F, Islam Z, Shah BN. Lesson of the month 1: Obesity hypoventilation (Pickwickian) syndrome: a reversible cause of severe pulmonary hypertension. Clin Med (Lond) 2017; 17:578-581. [PMID: 29196363 PMCID: PMC6297698 DOI: 10.7861/clinmedicine.17-6-578] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Obesity hypoventilation syndrome (OHS) is a condition in which an individual with a body mass index >30 kg/m2 develops daytime alveolar hypoventilation (defined as a resting PaCO2 >45 mmHg) that cannot be attributed to other pathologies. It is a condition with increasing prevalence and rising cost to healthcare systems worldwide. Right heart failure and pulmonary hypertension are well-known complications of this syndrome. Here, we present the case of a female patient with OHS who presented to our centre with severe pulmonary hypertension, which resolved with appropriate treatment. We also review this clinical condition and its diagnosis and management.
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Affiliation(s)
- Frazer Warricker
- Department of Cardiology, University Hospital Southampton, Southampton, UK
| | - Zafir Islam
- Department of Cardiology, University Hospital Southampton, Southampton, UK
| | - Benoy N Shah
- Department of Cardiology, University Hospital Southampton, Southampton, UK
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Effect of arterial puncture on ventilation. Heart Lung 2017; 46:149-152. [PMID: 28392039 DOI: 10.1016/j.hrtlng.2017.01.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2016] [Revised: 01/30/2017] [Accepted: 01/31/2017] [Indexed: 11/24/2022]
Abstract
BACKGROUND Clinicians frequently assume that during arterial puncture for measuring arterial blood gases patients hyperventilate from pain and anxiety. This assumption leads clinicians to falsely interpret a PaCO2 and pH near the upper limit of normal as a chronic respiratory acidosis corrected by an acute respiratory alkalosis. OBJECTIVE Determine if participants hyperventilate during arterial puncture from pain and anxiety. METHODS We recruited participants from a pulmonary function laboratory referred for arterial blood gas measurement. We excluded those with heart failure and included those with any respiratory condition (COPD, asthma, sleep apnea). We measured end tidal PCO2 (PETCO2), respiratory rate, and heart rate 15 min before topical anesthesia, during anesthesia, during arterial puncture, and 15 min later. We assessed generalized anxiety before and measured pain during and after arterial puncture. RESULTS 24 participants were recruited (age: 54 ± 12 years; men: 54%). PaCO2 was 41 ± 5 mmHg. One had acute respiratory alkalosis. Respiratory rate increased from (19 ± 6 breaths per minute (bpm)) before to a maximum (21 ± 6 bpm) during arterial puncture (p = 0.001). Heart rate was stable throughout. The lowest PETCO2 during the procedure (35 ± 5) was similar to PETCO2 before the procedure (p = 0.1). The change in PETCO2 and respiratory rate did not correlate with pain, anxiety, or lung function. CONCLUSION Respiratory rate increased slightly during arterial puncture without any change in PETCO2. Hence, acid-base status must be interpreted without the assumption of procedure induced hyperventilation.
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Reduced Cardiovascular Morbidity in Obesity-Hypoventilation Syndrome: An Ischemic Preconditioning Protective Effect? Chest 2016; 150:5-6. [PMID: 27396770 DOI: 10.1016/j.chest.2016.02.659] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 02/06/2016] [Indexed: 10/21/2022] Open
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Georges M, Nguyen-Baranoff D, Griffon L, Foignot C, Bonniaud P, Camus P, Pepin JL, Rabec C. Usefulness of transcutaneous PCO2to assess nocturnal hypoventilation in restrictive lung disorders. Respirology 2016; 21:1300-6. [DOI: 10.1111/resp.12812] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Revised: 02/04/2016] [Accepted: 02/12/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Marjolaine Georges
- Pulmonary Departement and Respiratory Critical Care Unit; University Hospital Dijon; Dijon France
- School of Medicine; Inserm U 866; University of Burgundy; Dijon France
| | - Danièle Nguyen-Baranoff
- Pulmonary Departement and Respiratory Critical Care Unit; University Hospital Dijon; Dijon France
| | - Lucie Griffon
- Pulmonary Departement and Respiratory Critical Care Unit; University Hospital Dijon; Dijon France
| | - Clement Foignot
- Pulmonary Departement and Respiratory Critical Care Unit; University Hospital Dijon; Dijon France
| | - Philippe Bonniaud
- Pulmonary Departement and Respiratory Critical Care Unit; University Hospital Dijon; Dijon France
- School of Medicine; Inserm U 866; University of Burgundy; Dijon France
| | - Philippe Camus
- Pulmonary Departement and Respiratory Critical Care Unit; University Hospital Dijon; Dijon France
- School of Medicine; Inserm U 866; University of Burgundy; Dijon France
| | - Jean-Louis Pepin
- Sleep, Exercise and Physiology Laboratory, EFCR; Grenoble University Hospital; Grenoble France
- Inserm U 1042, HP2; University of Grenoble Alpes; Grenoble France
| | - Claudio Rabec
- Pulmonary Departement and Respiratory Critical Care Unit; University Hospital Dijon; Dijon France
- School of Medicine; Inserm U 866; University of Burgundy; Dijon France
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Marik PE, Chen C. The clinical characteristics and hospital and post-hospital survival of patients with the obesity hypoventilation syndrome: analysis of a large cohort. Obes Sci Pract 2016; 2:40-47. [PMID: 27812378 PMCID: PMC5067555 DOI: 10.1002/osp4.27] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 12/04/2015] [Accepted: 12/16/2015] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE The worldwide prevalence of obesity has reached epidemic proportions. Obesity hypoventilation syndrome (OHS) is a common yet largely undiagnosed and mistreated condition that likely carries a high mortality. The aim of this study was to determine the clinical characteristics, hospital outcome, outcome following hospital discharge and predictors of death in a large cohort of patients hospitalized with OHS. OHS is an important condition as many patients with this syndrome are misdiagnosed and receive inappropriate treatment. METHODS We reviewed the electronic medical records of patients with unequivocal OHS admitted to a 525-bed tertiary-care teaching hospital over a 5-year period. Demographic and clinical data as well as hospital disposition were recorded. In order to determine the patients' post-discharge status, we linked our database to the database of death certificates of the State Registrar of Vital Records. RESULTS We identified 600 patients who met the inclusion criteria for this study. The patients' mean age was 58 ± 15 years with a mean body mass index of 48.2 ± 8.3 kg m-2; 64% were women. Thirty-seven percent had a history of diabetes and 43% had been misdiagnosed as having chronic obstructive pulmonary disease, while none had been previously diagnosed with OHS. The most common admission diagnoses were respiratory failure, heart failure and sepsis. Ninety (15%) patients died during the index hospitalization. The patients' age, S-creatinine, respiratory failure, sepsis and admission to the ICU were independent predictors of hospital mortality. The hospital survivors were followed for a mean of 1,174 ± 501 d (3.2 ± 1.3 years) from the index hospitalization. On follow-up, 98 of the 510 (19%) hospital survivors died, with an overall cumulative mortality of 31.3%. The patients' age, S-creatinine and admission to the ICU were independent predictors of post-hospital mortality. CONCLUSION Obesity hypoventilation syndrome is a common disease that is frequently misdiagnosed and mistreated and carries a 3-year morality, which is significantly worse than that for most cancers combined. Considering the high mortality of this disease, all patients with a body mass index > 35 kg m-2 should be screened for OHS; those patients with both early and established OHS should be referred to a pulmonary and/or sleep specialist for evaluation for non-invasive positive pressure ventilation, to a dietician for dietary counseling and lifestyle modification and to a bariatric surgeon for evaluation for bariatric surgery.
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Affiliation(s)
- P E Marik
- Division of Pulmonary and Critical Care Medicine Eastern Virginia Medical School Norfolk VA USA
| | - C Chen
- Division of Pulmonary and Critical Care Medicine Eastern Virginia Medical School Norfolk VA USA
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Abstract
Obesity hypoventilation syndrome is becoming an increasingly encountered condition both in respiratory outpatient clinics and in hospitalized patients. The health consequences and social disadvantages of obesity hypoventilation syndrome are significant. Unfortunately, the diagnosis and institution of appropriate therapy is commonly delayed when the syndrome is not recognized or misdiagnosed. Positive airway pressure therapy remains the mainstay of treatment and is effective in controlling sleep-disordered breathing and improving awake blood gases in the majority of individuals. Evidence supporting one mode of therapy over another is limited. Both continuous and bilevel therapy modes can successfully improve daytime gas exchange, with adherence to therapy an important modifiable factor in the response to treatment. Despite adherence to therapy, these individuals continue to experience excess mortality primarily due to cardiovascular events compared with those with eucapnic sleep apnea using CPAP. This difference likely arises from ongoing systemic inflammation secondary to the morbidly obese state. The need for a comprehensive approach to managing nutrition, weight, and physical activity in addition to reversal of sleep-disordered breathing is now widely recognized. Future studies need to evaluate the impact of a more aggressive and comprehensive treatment plan beyond managing sleep-disordered breathing. The impact of early identification and treatment of sleep-disordered breathing on the development and reversal of cardiometabolic dysfunction also requires further attention.
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Affiliation(s)
- Amanda Piper
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney Local Health District, Sydney, Camperdown, and Woolcock Institute of Medical Research, University of Sydney, Sydney, NSW, Australia.
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Palm A, Midgren B, Janson C, Lindberg E. Gender differences in patients starting long-term home mechanical ventilation due to obesity hypoventilation syndrome. Respir Med 2016; 110:73-8. [DOI: 10.1016/j.rmed.2015.11.010] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 11/22/2015] [Accepted: 11/23/2015] [Indexed: 11/28/2022]
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Masa JF, Corral J, Alonso ML, Ordax E, Troncoso MF, Gonzalez M, Lopez-Martínez S, Marin JM, Marti S, Díaz-Cambriles T, Chiner E, Aizpuru F, Egea C. Efficacy of Different Treatment Alternatives for Obesity Hypoventilation Syndrome. Pickwick Study. Am J Respir Crit Care Med 2015; 192:86-95. [DOI: 10.1164/rccm.201410-1900oc] [Citation(s) in RCA: 168] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Hodgson LE, Murphy PB, Hart N. Respiratory management of the obese patient undergoing surgery. J Thorac Dis 2015; 7:943-52. [PMID: 26101653 DOI: 10.3978/j.issn.2072-1439.2015.03.08] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 01/30/2015] [Indexed: 01/05/2023]
Abstract
As a reflection of the increasing global incidence of obesity, there has been a corresponding rise in the proportion of obese patients undergoing major surgery. This review reports the physiological effect of these changes in body composition on the respiratory system and discusses the clinical approach required to maximize safety and minimize the risk to the patient. The changes in respiratory system compliance and lung volumes, which can adversely affect pulmonary gas exchange, combined with upper airways obstruction and sleep-disordered breathing need to be considered carefully in the peri-operative period. Indeed, these challenges in the obese patient have led to a clear focus on the clinical management strategy and development of peri-operative pathways, including pre-operative risk assessment, patient positioning at induction and under anesthesia, modified approach to intraoperative ventilation and the peri-operative use of non-invasive ventilation (NIV) and continuous positive airways pressure.
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Affiliation(s)
- Luke E Hodgson
- 1 Lane Fox Respiratory Unit Guy's & St Thomas' NHS Foundation Trust, London, UK ; 2 Division of Asthma, Allergy and Lung Biology, King's College London, UK ; 3 Lane Fox Clinical Respiratory Physiology Research Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Patrick B Murphy
- 1 Lane Fox Respiratory Unit Guy's & St Thomas' NHS Foundation Trust, London, UK ; 2 Division of Asthma, Allergy and Lung Biology, King's College London, UK ; 3 Lane Fox Clinical Respiratory Physiology Research Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK
| | - Nicholas Hart
- 1 Lane Fox Respiratory Unit Guy's & St Thomas' NHS Foundation Trust, London, UK ; 2 Division of Asthma, Allergy and Lung Biology, King's College London, UK ; 3 Lane Fox Clinical Respiratory Physiology Research Centre, Guy's & St Thomas' NHS Foundation Trust, London, UK
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Monneret D. Bicarbonate or Base Excess in Early Obesity Hypoventilation Syndrome. Chest 2015; 147:e231. [DOI: 10.1378/chest.15-0189] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Manuel AR, Hart N, Stradling JR. Is a Raised Bicarbonate, Without Hypercapnia, Part of the Physiologic Spectrum of Obesity-Related Hypoventilation? Chest 2015; 147:362-368. [DOI: 10.1378/chest.14-1279] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Abstract
Obesity hypoventilation syndrome is a respiratory consequence of morbid obesity that is characterized by alveolar hypoventilation during sleep and wakefulness. The disorder involves a complex interaction between impaired respiratory mechanics, ventilatory drive and sleep-disordered breathing. Early diagnosis and treatment is important, because delay in treatment is associated with significant mortality and morbidity. Available treatment options include non-invasive positive airway pressure (PAP) therapies and weight loss. There is limited long-term data regarding the effectiveness of such therapies. This review outlines the current concepts of clinical presentation, diagnostic and management strategies to help identify and treat patients with obesity-hypoventilation syndromes.
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Balachandran JS, Masa JF, Mokhlesi B. Obesity Hypoventilation Syndrome Epidemiology and Diagnosis. Sleep Med Clin 2014; 9:341-347. [PMID: 25360072 DOI: 10.1016/j.jsmc.2014.05.007] [Citation(s) in RCA: 83] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Affiliation(s)
- Jay S Balachandran
- Sleep Disorders Center, Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, 5841 South Maryland Avenue, Chicago, IL 60637, USA
| | - Juan Fernando Masa
- Pulmonary Division, San Pedro de Alcantara Hospital, Avda. Pablo Naranjo s/n, Caceres 10003, Spain ; CIBERES National Research Network, Avd. Montforte de Lemos 5, Pabellon 11, Madrid 28029, Spain
| | - Babak Mokhlesi
- Sleep Disorders Center, Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, 5841 South Maryland Avenue, Chicago, IL 60637, USA
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Respiratory Determinants of Diurnal Hypercapnia in Obesity Hypoventilation Syndrome. What Does Weight Have to Do with It? Ann Am Thorac Soc 2014; 11:945-50. [DOI: 10.1513/annalsats.201403-099oc] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Hart N, Mandal S, Manuel A, Mokhlesi B, Pepin JL, Piper A, Stradling J. Rebuttal: ‘Obesity hypoventilation syndrome (OHS): does the current definition need revisiting?’. Thorax 2014; 69:955. [DOI: 10.1136/thoraxjnl-2014-205656] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Lemyze M, Taufour P, Duhamel A, Temime J, Nigeon O, Vangrunderbeeck N, Barrailler S, Gasan G, Pepy F, Thevenin D, Mallat J. Determinants of noninvasive ventilation success or failure in morbidly obese patients in acute respiratory failure. PLoS One 2014; 9:e97563. [PMID: 24819141 PMCID: PMC4018299 DOI: 10.1371/journal.pone.0097563] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2013] [Accepted: 04/21/2014] [Indexed: 11/19/2022] Open
Abstract
PURPOSE Acute respiratory failure (ARF) is a common life-threatening complication in morbidly obese patients with obesity hypoventilation syndrome (OHS). We aimed to identify the determinants of noninvasive ventilation (NIV) success or failure for this indication. METHODS We prospectively included 76 consecutive patients with BMI>40 kg/m2 diagnosed with OHS and treated by NIV for ARF in a 15-bed ICU of a tertiary hospital. RESULTS NIV failed to reverse ARF in only 13 patients. Factors associated with NIV failure included pneumonia (n = 12/13, 92% vs n = 9/63, 14%; p<0.0001), high SOFA (10 vs 5; p<0.0001) and SAPS2 score (63 vs 39; p<0.0001) at admission. These patients often experienced poor outcome despite early resort to endotracheal intubation (in-hospital mortality, 92.3% vs 17.5%; p<0.001). The only factor significantly associated with successful response to NIV was idiopathic decompensation of OHS (n = 30, 48% vs n = 0, 0%; p = 0.001). In the NIV success group (n = 63), 33 patients (53%) experienced a delayed response to NIV (with persistent hypercapnic acidosis during the first 6 hours). CONCLUSIONS Multiple organ failure and pneumonia were the main factors associated with NIV failure and death in morbidly obese patients in hypoxemic ARF. On the opposite, NIV was constantly successful and could be safely pushed further in case of severe hypercapnic acute respiratory decompensation of OHS.
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Affiliation(s)
- Malcolm Lemyze
- Department of Respiratory and Critical Care Medicine, Schaffner Hospital, Lens, France
| | - Pauline Taufour
- Department of Respiratory and Critical Care Medicine, Schaffner Hospital, Lens, France
| | - Alain Duhamel
- Department of Biostatistics, Lille University Hospital, CHRU Lille, France
| | - Johanna Temime
- Department of Respiratory and Critical Care Medicine, Schaffner Hospital, Lens, France
| | - Olivier Nigeon
- Respiratory Step Down Unit, Schaffner Hospital, Lens, France
| | | | - Stéphanie Barrailler
- Department of Respiratory and Critical Care Medicine, Schaffner Hospital, Lens, France
| | - Gaëlle Gasan
- Department of Respiratory and Critical Care Medicine, Schaffner Hospital, Lens, France
| | - Florent Pepy
- Department of Respiratory and Critical Care Medicine, Schaffner Hospital, Lens, France
| | - Didier Thevenin
- Department of Respiratory and Critical Care Medicine, Schaffner Hospital, Lens, France
| | - Jihad Mallat
- Department of Respiratory and Critical Care Medicine, Schaffner Hospital, Lens, France
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Affiliation(s)
- Aiman Tulaimat
- Department of Pulmonary, Critical Care, and Sleep Medicine, John H Stroger Hospital of Cook County, , Chicago, Illinois, USA
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