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Brown LK. Targeting Hypercapnia in Chronic Lung Disease and Obesity Hypoventilation: Benefits and Challenges. Sleep Med Clin 2024; 19:357-369. [PMID: 38692758 DOI: 10.1016/j.jsmc.2024.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Abstract
Hypoventilation is a complication that is not uncommon in chronic obstructive pulmonary disease and calls for both medical treatment of the underlying disease and, frequently, noninvasive ventilation either during exacerbations requiring hospitalization or in a chronic state in the patient at home. Obesity hypoventilation syndrome by definition is associated with ventilatory failure and hypercapnia. It may or may not be accompanied by obstructive sleep apnea, which when detected becomes an additional target for positive airway pressure treatment. Intensive research has not completely resolved the best choice of treatment, and the simplest modality, continuous positive airway pressure, may still be entertained.
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Affiliation(s)
- Lee K Brown
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA.
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2
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Arterial bicarbonate is associated with hypoxic burden and uncontrolled hypertension in obstructive sleep apnea - The ESADA cohort. Sleep Med 2023; 102:39-45. [PMID: 36599194 DOI: 10.1016/j.sleep.2022.11.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 11/29/2022] [Accepted: 11/30/2022] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Blood bicarbonate concentration plays an important role for obstructive sleep apnea (OSA) patients to maintain acid-base balance. We investigated the association between arterial standard bicarbonate ([HCO3-]) and nocturnal hypoxia as well as comorbid hypertension in OSA. METHODS A cross-sectional analysis of 3329 patients in the European Sleep Apnea Database (ESADA) was performed. Arterial blood gas analysis and lung function test were performed in conjunction with polysomnographic sleep studies. The 4% oxygen desaturation index (ODI), mean and minimum oxygen saturation (SpO2), and percentage of time with SpO2 below 90% (T90%) were used to reflect nocturnal hypoxic burden. Arterial hypertension was defined as a physician diagnosis of hypertension with ongoing antihypertensive medication. Hypertensive patients with SBP/DBP below or above 140/90 mmHg were classified as controlled-, uncontrolled hypertension, respectively. RESULTS The [HCO3-] level was normal in most patients (average 24.0 ± 2.5 mmol/L). ODI, T90% increased whereas mean and minimum SpO2 decreased across [HCO3-] tertiles (ANOVA, p = 0.030, <0.001, <0.001, and <0.001, respectively). [HCO3-] was independently associated with ODI, mean SpO2, minimum SpO2, and T90% after adjusting for confounders (β value [95%CI]: 1.21 [0.88-1.54], -0.16 [-0.20 to -0.11], -0.51 [-0.64 to -0.37], 1.76 [1.48-2.04], respectively, all p < 0.001). 1 mmol/L elevation of [HCO3-] was associated with a 4% increased odds of uncontrolled hypertension (OR: 1.04 [1.01-1.08], p = 0.013). CONCLUSION We first demonstrated an independent association between [HCO3-] and nocturnal hypoxic burden as well as uncontrolled hypertension in OSA patients. Bicarbonate levels as an adjunctive measure provide insight into the pathophysiology of hypertension in OSA.
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Tyagi A, Goyal A, Chaware P, Rathinam BA. Mutations of PHOX2B Gene in Patients of Obesity Hypoventilation Syndrome in Central India. J Lab Physicians 2021; 14:164-168. [PMID: 35982870 PMCID: PMC9381314 DOI: 10.1055/s-0041-1735582] [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] [Indexed: 10/27/2022] Open
Abstract
Abstract
Background Paired-like homeobox 2B (PHOX2B) gene on chromosome 4p12 codes for a transcription factor having a role in the formation of noradrenergic neuronal circuits. Its mutations have been linked to congenital central hypoventilation syndrome (CCHS). The clinical presentation of both, obesity hypoventilation syndrome (OHS) and CCHS in adults (named late-onset central hypoventilation syndrome), is quite similar. Because of this symptomatic similarity, multifactorial causation of OHS, the mutation of PHOX2B gene was studied in patients with OHS in this study.
Methods A hospital-based cross-sectional study was performed on patients diagnosed with OHS. The deoxyribonucleic acid was extracted from 2 mL of venous blood and was further amplified, specific to exon 3. The amplified products were cast and run in 2% agarose gel and then subjected to Sanger sequencing.
Results Thirty patients of OHS (21 male; 9 female) were enrolled in the present study, average age being 51.7 years. The Sanger sequencing of the samples revealed no apparent areas of deletions and no apparent mutations.
Conclusion Primers for exon 3 were used for amplification in thermocycler, as exon 3 is the most frequently mutated exon for PHOX2B gene, as per existing literature. The entire gene needs to be studied for mutations and the sample size needs to be increased.
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Affiliation(s)
- Ankita Tyagi
- Department of Anatomy, All India Institute of Medical Sciences Bhopal, Bhopal, Madhya Pradesh, India
| | - Abhishek Goyal
- Department of Pulmonary Medicine, All India Institute of Medical Sciences Bhopal, Bhopal, Madhya Pradesh, India
| | - Prashant Chaware
- Department of Anatomy, All India Institute of Medical Sciences Bhopal, Bhopal, Madhya Pradesh, India
| | - Bertha A.D. Rathinam
- Department of Anatomy, All India Institute of Medical Sciences Bhopal, Bhopal, Madhya Pradesh, India
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4
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Anderson DE, Reeves AN, Mehling WE, Chesney MA. Capnometric feedback training decreases 24-h blood pressure in hypertensive postmenopausal women. BMC Cardiovasc Disord 2021; 21:447. [PMID: 34535068 PMCID: PMC8447506 DOI: 10.1186/s12872-021-02240-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 08/28/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND High normal resting pCO2 is a risk factor for salt sensitivity of blood pressure (BP) in normotensive humans and has been associated with higher resting systolic BP in postmenopausal women. To date, however, no known studies have investigated the effects of regular practice of voluntary mild hypocapnic breathing on BP in hypertensive patients. The objective of the present research was to test the hypothesis that capnometric feedback training can decrease both resting pCO2 and 24-h BP in a series of mildly hypertensive postmenopausal women. METHODS A small portable end tidal CO2 (etCO2) monitor was constructed and equipped with software that determined the difference between the momentary etCO2 and a pre-programmed criterion range. The monitor enabled auditory feedback for variations in CO2 outside the criterion range. 16 mildly hypertensive postmenopausal women were individually trained to sustain small decreases in etCO2 during six weekly sessions in the clinic and daily sessions at home. 24-h BP monitoring was conducted before and after the intervention, and in 16 prehypertensive postmenopausal women in a control group who did not engage in the capnometric training. RESULTS Following the intervention, all 16 capnometric training participants showed decreases in resting etCO2 (- 4.3 ± 0.4 mmHg; p < .01) while 15 showed decreases in 24-h systolic BP (- 7.6 ± 2.0 mmHg; p < .01). No significant changes in either measure was observed in the control group. In addition, nighttime (- 9.5 ± 2.6; p < .01) and daytime (- 6.7 ± 0.2 mmHg) systolic BP were both decreased following capnometric training, while no significant changes in nighttime (- 2.8 ± 2.2 mmHg; p = .11) or daytime (- 0.7 ± 1.0 mmHg; p ≤ .247) systolic BP were observed in the control group. CONCLUSIONS These findings support the hypothesis that regular practice of mild hypocapnic breathing that decreases resting etCO2 reliably decreases 24-h blood pressure in hypertensive postmenopausal women. The extent to which these effects persist beyond the training period or can be observed in other hypertensive subgroups remains to be investigated.
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Affiliation(s)
- David E Anderson
- Department of Medicine, School of Medicine, University of California, San Francisco, San Francisco, CA, 415-613-7343, USA
| | - Alexis N Reeves
- Department of Medicine, School of Medicine, University of California, San Francisco, San Francisco, CA, 415-613-7343, USA
| | - Wolf E Mehling
- Department of Family and Community Medicine, School of Medicine, University of California, San Francisco, San Francisco, USA
| | - Margaret A Chesney
- Department of Medicine, School of Medicine, University of California, San Francisco, San Francisco, CA, 415-613-7343, USA.
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Orr JE, Azofra AS, Tobias LA. Management of Chronic Respiratory Failure in Chronic Obstructive Pulmonary Disease: High-Intensity and Low-Intensity Ventilation. Sleep Med Clin 2021; 15:497-509. [PMID: 33131660 DOI: 10.1016/j.jsmc.2020.08.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
A significant body of literature supports the benefit of noninvasive ventilation (NIV) for acute hypercapnia in the setting of exacerbations of chronic obstructive pulmonary disease (COPD). In those with severe COPD with chronic hypercapnic respiratory failure, however, the role of NIV has been more controversial. This article reviews the physiologic basis for considering NIV in patients with COPD, summarizes existing evidence supporting the role of NIV in COPD, highlights the patient population and ventilatory approach most likely to offer benefit, and suggests a potential clinical pathway for managing patients.
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Affiliation(s)
- Jeremy E Orr
- Division of Pulmonary, Critical Care, and Sleep Medicine, UC San Diego School of Medicine, 9300 Campus Point Drive, MC 7381, La Jolla, CA 92130, USA.
| | - Ana Sanchez Azofra
- Hospital Universitario de la Princesa, Calle Diego de León 62, Madrid 28006, Spain
| | - Lauren A Tobias
- Veterans Affairs Connecticut Healthcare System, Yale University School of Medicine, 950 Campbell Avenue, West Haven, CT 06516, USA
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Dursun M, Selimoğlu Şen H, Yılmaz S, Demir M, Kırbaş G, Taylan M. Serum bicarbonate level improves specificity of Berlin Sleep Questionnaire for obstructive sleep apnea. Aging Male 2020; 23:1480-1486. [PMID: 32752912 DOI: 10.1080/13685538.2020.1801623] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Several questionnaires have been developed to assist the diagnostic process in obstructive sleep apnea syndrome (OSAS). Berlin Sleep Questionnaire (BSQ) represents a validated screening tool for OSAS. Totally 450 patients admitted to the Sleep Center at Dicle University Medical Faculty were included prospectively. A risk analysis was performed for presence of OSAS using the BSQ. Arterial blood gas measurements were performed including bicarbonate (HCO3) level. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of BSQ for presence of OSAS and severe OSAS were determined. In patients with arterial HCO3 >24.94 mEq/L; sensitivity, specificity, PPV and NPV, of the BSQ were 93.04, 57.1, 98.3, and 23.5%, respectively. The addition of arterial HCO3 value increased the sensitivity of the BSQ in detecting OSAS patients. Although the cost of sleep studies is high for false positives from the BSQ plus arterial HCO3 level, this cost should be compared with the loss of work efficiency and severe healthcare costs of undiagnosed cases in the future. Therefore, finding possible OSAS cases in primary care health centers is important and adding serum HCO3 value to BSQ questionnaire may contribute to this topic.
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Affiliation(s)
- Mazlum Dursun
- Department of Chest Diseases, Dicle University School of Medicine, Diyarbakir, Turkey
| | - Hadice Selimoğlu Şen
- Department of Chest Diseases, Dicle University School of Medicine, Diyarbakir, Turkey
| | - Süreyya Yılmaz
- Department of Chest Diseases, Dicle University School of Medicine, Diyarbakir, Turkey
| | - Melike Demir
- Department of Chest Diseases, Dicle University School of Medicine, Diyarbakir, Turkey
| | - Gökhan Kırbaş
- Department of Chest Diseases, Dicle University School of Medicine, Diyarbakir, Turkey
| | - Mahşuk Taylan
- Department of Chest Diseases, Gaziantep University School of Medicine, Gaziantep, Turkey
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Si L, Zhang J, Wang Y, Cao J, Chen BY, Guo HJ. Obstructive sleep apnea and respiratory center regulation abnormality. Sleep Breath 2020; 25:563-570. [PMID: 32870421 DOI: 10.1007/s11325-020-02175-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 08/14/2020] [Accepted: 08/19/2020] [Indexed: 11/27/2022]
Abstract
PURPOSE Obstructive sleep apnea (OSA) is a complex disease in which phenotypic analysis and understanding pathological mechanisms facilitate personalized treatment and outcomes. However, the pathophysiology responsible for this robust observation is incompletely understood. The objective of the present work was to review how respiratory center regulation varies during sleep and wakeness in patients with OSA. DATA SOURCES We searched for relevant articles up to December 31, 2019 in PubMed database. METHODS This review examines the current literature on the characteristics of respiratory center regulation during wakefulness and sleep in OSA, detection method, and phenotypic treatment for respiratory center regulation. RESULTS Mechanisms for ventilatory control system instability leading to OSA include different sleep stages in chemoresponsiveness to hypoxia and hypercapnia and different chemosensitivity at different time. One can potentially stabilize the breathing center in sleep-related breathing disorders by identifying one or more of these pathophysiological mechanisms. CONCLUSIONS Advancing mechanism research in OSA will guide symptom research and provide alternate and novel opportunities for effective treatment for patients with OSA.
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Affiliation(s)
- Liang Si
- Respiratory Department, Tianjin Medical University General Hospital, Tianjin, 300052, China
| | - Jing Zhang
- Respiratory Department, Tianjin Medical University General Hospital, Tianjin, 300052, China
| | - Yan Wang
- Respiratory Department, Tianjin Medical University General Hospital, Tianjin, 300052, China
| | - Jie Cao
- Respiratory Department, Tianjin Medical University General Hospital, Tianjin, 300052, China.
| | - Bao-Yuan Chen
- Respiratory Department, Tianjin Medical University General Hospital, Tianjin, 300052, China.
| | - Heng-Juan Guo
- Respiratory Department, Tianjin Medical University General Hospital, Tianjin, 300052, China
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Pouwels S, Buise MP, Twardowski P, Stepaniak PS, Proczko M. Obesity Surgery and Anesthesiology Risks: a Review of Key Concepts and Related Physiology. Obes Surg 2020; 29:2670-2677. [PMID: 31127496 DOI: 10.1007/s11695-019-03952-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The obesity epidemic is swelling to epic proportions. Obese patients often suffer from a combination of hypertension, dyslipidemia, and type 2 diabetes mellitus (T2DM), also known as the "metabolic syndrome." The metabolic syndrome is an independent predictor of cardiac dysfunction and cardiovascular disease and a risk factor for perioperative morbidity and mortality. In this paper, we discuss the perioperative risk factors and the need for advanced care of obese patients needing general anesthesia for (bariatric) surgical procedures based on physiological principles.
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Affiliation(s)
- Sjaak Pouwels
- Department of Surgery, Haaglanden Medical Center, Lijnbaan 32, 2512 VA, The Hague, The Netherlands.
| | - Marc P Buise
- Department of Anesthesiology, Intensive Care and Pain Medicine, Catharina Hospital, Eindhoven, The Netherlands
| | - Pawel Twardowski
- Department of Anesthesia and Intensive Care, University Medical Center, Gdansk University, Gdansk, Poland
| | - Pieter S Stepaniak
- Department of Operating Rooms, Catharina Hospital, Eindhoven, The Netherlands
| | - Monika Proczko
- Department of Surgery, University Medical Center, Gdansk University, Gdansk, Poland
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9
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Canales MT, Bozorgmehri S, Ishani A, Weiner ID, Berry R, Beyth R. Prevalence and correlates of sleep apnea among US Veterans with chronic kidney disease. J Sleep Res 2020; 29:e12981. [PMID: 31912641 DOI: 10.1111/jsr.12981] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 10/30/2019] [Accepted: 12/12/2019] [Indexed: 12/12/2022]
Abstract
The prevalence and correlates of sleep apnea (SA) among Veterans with chronic kidney disease (CKD), a population at high risk of both SA and CKD, are unknown. We performed a cross-sectional analysis of 248 Veterans (18-89 years) selected only for presence of moderate to severe CKD. All participants underwent full, unattended polysomnography, measurement of renal function and a sleepiness questionnaire. Logistic regression with backward selection was used to identify predictors of prevalent SA (apnea-hypopnea index [AHI, ≥15 events/hr] and prevalent nocturnal hypoxia [NH, % of total sleep time spent at <90% oxygen saturation]). The mean age of our cohort was 73.2 ± 9.6 years, 95% were male, 78% were Caucasian and the mean body mass index (BMI) was 30.3 ± 4.8 kg/m2 . The prevalence of SA was 39%. There was no difference in daytime sleepiness among those with and without SA. In the final model, older age, higher BMI and diabetes mellitus (DM) were associated with higher odds of SA, after controlling for age, BMI, race and sex. Higher BMI, DM, unemployed/retired status, current smoking and higher serum bicarbonate level were associated with prevalent NH. To sum, SA was common among Veterans with moderate to severe CKD. Although some traditional risk factors for SA were associated with SA in this population, sleepiness did not correlate with SA. Further study is needed to validate our findings and understand how best to address the high burden of SA among Veterans with CKD.
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Affiliation(s)
- Muna T Canales
- Division of Nephrology, Department of Medicine, Malcom Randall VA Medical Center, University of Florida, Gainesville, FL, USA
| | - Shahab Bozorgmehri
- Division of Nephrology, Department of Medicine, Malcom Randall VA Medical Center, University of Florida, Gainesville, FL, USA
| | - Areef Ishani
- Minneapolis VA Medical Center, University of Minnesota, Minneapolis, MN, USA
| | - I David Weiner
- Division of Nephrology, Department of Medicine, Malcom Randall VA Medical Center, University of Florida, Gainesville, FL, USA
| | - Richard Berry
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Medicine, Malcom Randall VA Medical Center, University of Florida, Gainesville, FL, USA
| | - Rebecca Beyth
- Division of General Medicine, Department of Medicine, Malcom Randall VA Medical Center, University of Florida, Gainesville, FL, USA
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Reply: Carbon Dioxide Narcosis or Sleep Deprivation? Ann Am Thorac Soc 2019; 16:778. [PMID: 30916987 PMCID: PMC6543469 DOI: 10.1513/annalsats.201903-204le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Murphy PB, Suh ES, Hart N. Non-invasive ventilation for obese patients with chronic respiratory failure: Are two pressures always better than one? Respirology 2019; 24:952-961. [PMID: 31121638 DOI: 10.1111/resp.13588] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Revised: 04/10/2019] [Accepted: 05/02/2019] [Indexed: 01/02/2023]
Abstract
Obesity-related respiratory failure is increasingly common but remains under-diagnosed and under-treated. There are several clinical phenotypes reported, including severe obstructive sleep apnoea (OSA), isolated nocturnal hypoventilation with or without severe OSA and OSA complicating chronic obstructive pulmonary disease (COPD). The presence of hypercapnic respiratory failure is associated with poor clinical outcomes in each of these groups. While weight loss is a core aim of management, this is often unachievable, and treatment of sleep-disordered breathing with positive airway pressure (PAP) therapy is the mainstay of clinical practice. Although there are few long-term clinical efficacy trials, the lack of equipoise would prevent the utilization of an untreated control group. The current data support the use of PAP therapy to improve respiratory failure and is associated with improvements in health-related quality of life, reduced healthcare utilization and reduced mortality. Both continuous PAP (CPAP) and non-invasive ventilation (NIV) appear safe and effective in patients with obesity-related respiratory failure and OSA, with or without COPD, and the current evidence would not support a single therapy choice in all patients. There are no studies of CPAP in patients with isolated nocturnal hypoventilation, and NIV would be the current recommendation in this patient group. Whichever starting therapy is used, titration should be performed to correct sleep-disordered breathing and reverse chronic respiratory failure, with consideration of step-down of the treatment based on a clinical re-evaluation. In contrast, failure to reach physiological and clinical treatment targets should lead to the consideration of treatment escalation.
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Affiliation(s)
- Patrick B Murphy
- Lane Fox Respiratory Service, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Centre for Human and Applied Physiological Sciences, King's College London, London, UK
| | - Eui-Sik Suh
- Lane Fox Respiratory Service, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Centre for Human and Applied Physiological Sciences, King's College London, London, UK
| | - Nicholas Hart
- Lane Fox Respiratory Service, Guy's and St Thomas' NHS Foundation Trust, London, UK.,Centre for Human and Applied Physiological Sciences, King's College London, London, UK
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12
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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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13
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Pouwels S, Topal B, Knook MT, Celik A, Sundbom M, Ribeiro R, Parmar C, Ugale S. Interaction of obesity and atrial fibrillation: an overview of pathophysiology and clinical management. Expert Rev Cardiovasc Ther 2019; 17:209-223. [PMID: 30757925 DOI: 10.1080/14779072.2019.1581064] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Sjaak Pouwels
- Department of Surgery, Haaglanden Medical Center, The Hague, The Netherlands
| | - Besir Topal
- Department of Cardiothoracic Surgery, Amsterdam, The Netherlands
| | - Mireille T. Knook
- Department of Surgery, Haaglanden Medical Center, The Hague, The Netherlands
- Nederlandse Obesitas Kliniek West, The Hague, The Netherlands
| | | | - Magnus Sundbom
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Rui Ribeiro
- Centro Multidisciplinar da Doença Metabólica, Clínica de Santo António, Lisbon, Portugal
| | - Chetan Parmar
- Department of Surgery, Whittington Hospital, London, UK
| | - Surendra Ugale
- Bariatric & Metabolic Surgery Clinic, Kirloskar Hospital, Hyderabad, India
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Turnbull CD, Sen D, Kohler M, Petousi N, Stradling JR. Effect of Supplemental Oxygen on Blood Pressure in Obstructive Sleep Apnea (SOX). A Randomized Continuous Positive Airway Pressure Withdrawal Trial. Am J Respir Crit Care Med 2019; 199:211-219. [PMID: 30025470 PMCID: PMC6353003 DOI: 10.1164/rccm.201802-0240oc] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 07/06/2018] [Indexed: 01/19/2023] Open
Abstract
RATIONALE Obstructive sleep apnea (OSA) is associated with systemic hypertension. Either overnight intermittent hypoxia, or the recurrent arousals that occur in OSA, could cause the daytime increases in blood pressure (BP). OBJECTIVES To establish the role of intermittent hypoxia in the increased morning BP in patients with OSA. METHODS Randomized, double-blinded, crossover trial assessing the effects of overnight supplemental oxygen versus air (sham) on morning BP, after continuous positive airway pressure (CPAP) withdrawal in patients with moderate to severe OSA. The primary outcome was the change in home morning BP after CPAP withdrawal for 14 nights, oxygen versus air. Secondary outcomes included oxygen desaturation index (ODI), apnea-hypopnea index (AHI), subjective sleepiness (Epworth Sleepiness Scale score), and objective sleepiness (Oxford Sleep Resistance Test). MEASUREMENTS AND MAIN RESULTS Supplemental oxygen virtually abolished the BP rise after CPAP withdrawal and, compared with air, significantly reduced the rise in mean systolic BP (-6.6 mm Hg; 95% confidence interval [CI], -11.3 to -1.9; P = 0.008), mean diastolic BP (-4.6 mm Hg; 95% CI, -7.8 to -1.5; P = 0.006), and median ODI (-23.8/h; interquartile range, -31.0 to -16.3; P < 0.001) after CPAP withdrawal. There was no significant difference, oxygen versus air, in AHI, subjective sleepiness, or objective sleepiness. CONCLUSIONS Supplemental oxygen virtually abolished the rise in morning BP during CPAP withdrawal. Supplemental oxygen substantially reduced intermittent hypoxia, but had a minimal effect on markers of arousal (including AHI), subjective sleepiness, or objective sleepiness. Therefore intermittent hypoxia, and not recurrent arousals, appears to be the dominant cause of daytime increases in BP in OSA.
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Affiliation(s)
- Chris D. Turnbull
- National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Dushendree Sen
- Oxford Centre for Respiratory Medicine, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Malcolm Kohler
- Department of Pulmonology and Sleep Disorders Centre, University Hospital of Zurich, Zurich, Switzerland
- Centre for Integrative Human Physiology, University of Zurich, Zurich, Switzerland; and
| | - Nayia Petousi
- Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
| | - John R. Stradling
- National Institute for Health Research Oxford Biomedical Research Centre, University of Oxford, Oxford, United Kingdom
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Sivam S, Yee B, Wong K, Wang D, Grunstein R, Piper A. Obesity Hypoventilation Syndrome: Early Detection of Nocturnal-Only Hypercapnia in an Obese Population. J Clin Sleep Med 2018; 14:1477-1484. [PMID: 30176974 DOI: 10.5664/jcsm.7318] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2018] [Accepted: 05/09/2018] [Indexed: 01/19/2023]
Abstract
STUDY OBJECTIVES Hypoventilation in obesity is now divided into five stages; stage 0 (pure obstructive sleep apnea; OSA), stages I/II (obesity-related sleep hypoventilation; ORSH) and stages III/IV (awake hypercapnia, obesity hypoventilation syndrome; OHS). Hypercapnia during the day may be preceded by hypoventilation during sleep. The goal of this study was to determine the prevalence and to identify simple clinical measures that predict stages I/II ORSH. The effect of supine positioning on selected clinical measures was also evaluated. METHODS Ninety-four patients with a body mass index > 40 kg/m2 and a spirometric ratio > 0.7 were randomized to begin testing either in the supine or upright seated position on the day of their diagnostic sleep study. Arterialized capillary blood gases were measured in both positions. Oxygen saturation measured by pulse oximetry was also obtained while awake. Transcutaneous CO2 monitoring was performed during overnight polysomnography. RESULTS Stages I/II ORSH had a prevalence of 19% in an outpatient tertiary hospital setting compared with 61%, 17%, and 3% for stages 0, III/IV, and no sleep-disordered breathing respectively. Predictors for sleep hypoventilation in this group were an awake oxygen saturation of ≤ 93% (sensitivity 39%, specificity 98%, positive likelihood ratio of 22) and a partial pressure of carbon dioxide ≥ 45 mmHg (sensitivity 44%, specificity 98%, positive likelihood ratio of 24) measured in the supine position. CONCLUSIONS ORSH has a similar prevalence to OHS. Awake oxygen saturation and partial pressure of carbon dioxide performed in the supine position may help predict obese patients with sleep hypoventilation without awake hypercapnia. COMMENTARY A commentary on this article appears in this issue on page 1455. CLINICAL TRIAL REGISTRATION Registry: Australian New Zealand Clinical Trials Registry, Identifier: ACTRN 12615000135516, URL: https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=367493&isReview=true, Title: A cross-sectional study to identify obese patients who are at risk for developing obesity hypoventilation syndrome (OHS) by investigating the relationship between daytime measures (including supine hypercapnia, distribution of body fat and lung volumes) with the presence of hypoventilation during sleep.
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Affiliation(s)
- Sheila Sivam
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, Australia; School of Medicine, University of Sydney, Sydney, Australia; Woolcock Institute of Medical Research, Sleep and Circadian Research Group, Sydney, Australia
| | - Brendon Yee
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, Australia; School of Medicine, University of Sydney, Sydney, Australia; Woolcock Institute of Medical Research, Sleep and Circadian Research Group, Sydney, Australia
| | - Keith Wong
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, Australia; School of Medicine, University of Sydney, Sydney, Australia; Woolcock Institute of Medical Research, Sleep and Circadian Research Group, Sydney, Australia
| | - David Wang
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, Australia; School of Medicine, University of Sydney, Sydney, Australia; Woolcock Institute of Medical Research, Sleep and Circadian Research Group, Sydney, Australia
| | - Ronald Grunstein
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, Australia; School of Medicine, University of Sydney, Sydney, Australia; Woolcock Institute of Medical Research, Sleep and Circadian Research Group, Sydney, Australia
| | - Amanda Piper
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Sydney, Australia; School of Medicine, University of Sydney, Sydney, Australia; Woolcock Institute of Medical Research, Sleep and Circadian Research Group, Sydney, Australia
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Eskandari D, Zou D, Grote L, Schneider H, Penzel T, Hedner J. Independent associations between arterial bicarbonate, apnea severity and hypertension in obstructive sleep apnea. Respir Res 2017; 18:130. [PMID: 28659192 PMCID: PMC5490198 DOI: 10.1186/s12931-017-0607-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 06/08/2017] [Indexed: 01/01/2023] Open
Abstract
Background Obstructive sleep apnea is characterized by intermittent hypoxia and hypercapnia. CO2 production, transport and elimination are influenced by the carbonic anhydrase enzyme. We hypothesized that elevated standard bicarbonate, a proxy for increased carbonic anhydrase activity, is associated with apnea severity and higher blood pressure in patients with obstructive sleep apnea. Methods A retrospective analysis of a sleep apnea cohort (n = 830) studied by ambulatory polygraphy. Office systolic/diastolic blood pressure, lung function, and arterial blood gases were assessed during daytime. Results Arterial standard bicarbonate was increased with apnea severity (mild/moderate/severe 24.1 ± 1.8, 24.4 ± 1.7 and 24.9 ± 2.9 mmol/l, respectively, Kruskal-Wallis test p < 0.001). Standard bicarbonate was independently associated with apnea hypopnea index after adjustment for sex, age, body mass index, smoking, alcohol, hypertension, pO2 and pCO2 (standard bicarbonate quartile 1 vs. quartile 4, β = 10.6, p < 0.001). Log-transformed standard bicarbonate was associated with a diagnosis of hypertension or diastolic blood pressure but not systolic blood pressure adjusting for cofounders (p = 0.007, 0.048 and 0.45, respectively). Conclusions There was an independent association between sleep apnea severity and arterial standard bicarbonate. The link between high standard bicarbonate and daytime hypertension suggests that carbonic anhydrase activity may constitute a novel mechanism for blood pressure regulation in sleep apnea. Electronic supplementary material The online version of this article (doi:10.1186/s12931-017-0607-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Davoud Eskandari
- Center for Sleep and Vigilance Disorders, Department of Internal Medicine and Clinical Nutrition, Sahlgrenska Academy, University of Gothenburg, Medicinaregatan 8B, Box 421, SE-40530, Gothenburg, Sweden
| | - Ding Zou
- Center for Sleep and Vigilance Disorders, Department of Internal Medicine and Clinical Nutrition, Sahlgrenska Academy, University of Gothenburg, Medicinaregatan 8B, Box 421, SE-40530, Gothenburg, Sweden.
| | - Ludger Grote
- Center for Sleep and Vigilance Disorders, Department of Internal Medicine and Clinical Nutrition, Sahlgrenska Academy, University of Gothenburg, Medicinaregatan 8B, Box 421, SE-40530, Gothenburg, Sweden
| | - Hartmut Schneider
- Johns Hopkins Sleep Disorders Center, Division of Pulmonary and Critical Care Medicine, Johns Hopkins University, Baltimore, Maryland, USA
| | - Thomas Penzel
- Interdisciplinary Center of Sleep Medicine, Charité-Universitätsmedizin Berlin, Berlin, Germany.,International Clinical Research Center, St. Anne's University Hospital Brno, Brno, Czech Republic
| | - Jan Hedner
- Center for Sleep and Vigilance Disorders, Department of Internal Medicine and Clinical Nutrition, Sahlgrenska Academy, University of Gothenburg, Medicinaregatan 8B, Box 421, SE-40530, Gothenburg, Sweden
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Using PaCO2 values to grade obesity-hypoventilation syndrome severity: a retrospective study. Multidiscip Respir Med 2017; 12:14. [PMID: 28533903 PMCID: PMC5437582 DOI: 10.1186/s40248-017-0093-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2016] [Accepted: 04/14/2017] [Indexed: 11/10/2022] Open
Abstract
Background To date, an important aspect that has still not been clarified is the assessment of OHS severity. The purpose of this retrospective study was to evaluate whether grading OHS severity according to PaCO2 values may be useful in order to provide a more definite characterization and targeted management of patients. In this regard, baseline anthropometric and sleep polygraphic characteristics, treatment options, and follow up outcomes, were compared between OHS patients with different degree of severity (as assessed according to PaCO2 values). Methods Patients were classified into three groups, according to PaCO2 values: 1) mild (46 mmHg ≤ PaCO2 ≤ 50 mmHg), moderate (51 mmHg ≤ PaCO2 ≤ 55 mmHg), severe (PaCO2 ≥ 56 mmHg). Therefore, differences among the groups in terms of baseline anthropometric, and sleep polygraphic characteristics, treatment modalities and follow up outcomes were retrospectively evaluated. Results Patients with more severe degree of hypercapnia were assessed to have increased BMI and bicarbonate levels, worse diurnal and nocturnal hypoxemia, and a more severe impairment in pulmonary mechanics compared to milder OHS. CPAP responders rate significantly decreased from mild to severe OHS. After follow up, daytime sleepiness (as measure by the ESS), PaO2, and PaCO2 significantly improved with PAP therapy in all three groups. Discussion and Conclusions Classification of OHS severity according to PaCO2 levels may be useful to provide a more defined characterization and, consequently, a more targeted management of OHS patients. Further studies are needed to confirm our findings.
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Orfanos S, Jaffuel D, Perrin C, Molinari N, Chanez P, Palot A. Switch of noninvasive ventilation (NIV) to continuous positive airway pressure (CPAP) in patients with obesity hypoventilation syndrome: a pilot study. BMC Pulm Med 2017; 17:50. [PMID: 28288605 PMCID: PMC5348845 DOI: 10.1186/s12890-017-0391-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Accepted: 03/04/2017] [Indexed: 11/10/2022] Open
Abstract
Background Obesity is a major worldwide public health issue. The main respiratory complication stemming from obesity is obesity hypoventilation syndrome (OHS). Most of the OHS patients diagnosed during an exacerbation are treated with non invasive ventilation (NIV). Up to date, no prospective study has demonstrated in real life conditions the feasibility of a systematic protocoled switch of NIV to continuous positive airway pressure (CPAP), once stability is achieved. Methods In this prospective study, we included stable patients with OHS, with moderate to severe concomitant obstructive sleep apnea (OSA) and without obstructive pulmonary disease, who had been undergoing NIV for more than 2 months. The following measurements were performed, first with NIV and then after the switch to CPAP: diurnal arterial blood gas measurements; nocturnal oximetry and capnometry; mean compliance and AHI; measures of quality of life and quality of sleep. Results 22/30 patients accepted to participate in the study and 15/22 patients completed the study. There were no significant differences for pooled data in diurnal alveolar blood gases, nocturnal capnometry (p = 0.534), nocturnal oximetry (p = 0.218), mean compliance (p = 0.766), mean AHI (p = 0.334), quality of life or quality of sleep. Eighty percent of the patients treated in this study favored CPAP over NIV. Conclusion This pilot study showed in real life conditions the possibility of a systematic switch of NIV to CPAP, in most stable patients with OHS, with similar efficacy on diurnal and nocturnal alveolar gas exchange, quality of life and quality of sleep. Trial registration ISRCTN13981084. Registered: 27 February 2017 (retrospectively registered)
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Affiliation(s)
- Sarah Orfanos
- Aix-Marseille University, Faculté de médecine, 27 Boulevard Jean Moulin, 13005, Marseille, France.
| | - Dany Jaffuel
- Département de Pneumologie, Hôpital Arnaud de Villeneuve, CHRU de Montpellier, 371 Avenue du Doyen Giraud, 34295, Montpellier, Cedex 5, France
| | - Christophe Perrin
- Service de Pneumologie, Pôle des Spécialités Médicales, Centre Hospitalier de Cannes, 15 avenue des Broussailles, 06401, Cannes, France
| | - Nicolas Molinari
- INSERM U1046, Université de Montpellier 1 et Département Médical d'Information, Centre Hospitalier Universitaire, 34090, Montpellier, France
| | - Pascal Chanez
- Clinique des Bronches, Allergies et du Sommeil, Assistance Publique Hôpitaux de Marseille, France et INSERM U1067, CNRS UMR 7333 Aix Marseille Université, 13015, Marseille, France
| | - Alain Palot
- Clinique des Bronches, Allergies et du Sommeil, Assistance Publique Hôpitaux de Marseille, France et INSERM U1067, CNRS UMR 7333 Aix Marseille Université, 13015, Marseille, France
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Determinants of Wake Pco2 and Increases in Wake Pco2 over Time in Patients with Obstructive Sleep Apnea. Ann Am Thorac Soc 2016; 13:259-64. [PMID: 26636624 DOI: 10.1513/annalsats.201508-563oc] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE The progression from obesity and obstructive sleep apnea to obesity with hypoventilation and daytime hypercapnia may relate to features of sleep-disordered breathing events that affect loading and unloading of carbon dioxide. OBJECTIVES To determine whether the wake Pco2 increases over time in untreated obstructive sleep apnea, and whether that increase is explained by changes in sleep-disordered breathing event duration, interevent duration, or postevent ventilation amplitude. METHODS We selected 14 adults who had two polysomnographic studies more than 1 year apart because of untreated or suboptimally treated moderate to severe obstructive sleep apnea. Demographic and polysomnographic data were reviewed for both sets of studies, including the evening wake end-tidal CO2, the ratio of mean event to mean interevent duration (subsuming apneas and hypopneas), and the ratio of mean post- to preevent breath amplitude. MEASUREMENT AND MAIN RESULTS The mean (SD) wake end-tidal Pco2 increased between studies from 35.9 (4.2) to 39.5 (3.9) mm Hg (P < 0.005). The wake end-tidal CO2 correlated inversely with the post- to pre-event breath amplitude and positively with the ratio of mean event to mean interevent duration and with body mass index. However, those three variables were not significantly changed between the two studies. The wake end-tidal CO2 did not correlate with the apnea-hypopnea index or age. There was a significant increase in bicarbonate level between studies (median, 24.0-26.5 mmol/L; P = 0.01). CONCLUSIONS In our study cohort, wake end-tidal CO2 correlated with body mass index and features of sleep apnea that influence the balance of loading and unloading of CO2. However, those features remained fixed over time, even as the wake Pco2 and bicarbonate levels increased with untreated sleep apnea.
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Practical Recommendations for Diagnosis and Management of Respiratory Muscle Weakness in Late-Onset Pompe Disease. Int J Mol Sci 2016; 17:ijms17101735. [PMID: 27763517 PMCID: PMC5085764 DOI: 10.3390/ijms17101735] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Revised: 09/29/2016] [Accepted: 10/10/2016] [Indexed: 11/17/2022] Open
Abstract
Pompe disease is an autosomal-recessive lysosomal storage disorder characterized by progressive myopathy with proximal muscle weakness, respiratory muscle dysfunction, and cardiomyopathy (in infants only). In patients with juvenile or adult disease onset, respiratory muscle weakness may decline more rapidly than overall neurological disability. Sleep-disordered breathing, daytime hypercapnia, and the need for nocturnal ventilation eventually evolve in most patients. Additionally, respiratory muscle weakness leads to decreased cough and impaired airway clearance, increasing the risk of acute respiratory illness. Progressive respiratory muscle weakness is a major cause of morbidity and mortality in late-onset Pompe disease even if enzyme replacement therapy has been established. Practical knowledge of how to detect, monitor and manage respiratory muscle involvement is crucial for optimal patient care. A multidisciplinary approach combining the expertise of neurologists, pulmonologists, and intensive care specialists is needed. Based on the authors' own experience in over 200 patients, this article conveys expert recommendations for the diagnosis and management of respiratory muscle weakness and its sequelae in late-onset Pompe disease.
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Abstract
The prevalence of obesity hypoventilation syndrome and obstructive sleep apnea are increasing rapidly in the United States in parallel with the obesity epidemic. As the pathogenesis of this chronic illness is better understood, effective evidence-based therapies are being deployed to reduce morbidity and mortality. Nevertheless, patients with obesity hypoventilation still fall prey to at least four avoidable types of therapeutic errors, especially at the time of hospitalization for respiratory or cardiovascular decompensation: (1) patients with obesity hypoventilation syndrome may develop acute hypercapnia in response to administration of excessive supplemental oxygen; (2) excessive diuresis for peripheral edema using a loop diuretic such as furosemide exacerbates metabolic alkalosis, thereby worsening daytime hypoventilation and hypoxemia; (3) excessive or premature pharmacological treatment of psychiatric illnesses can exacerbate sleep-disordered breathing and worsen hypercapnia, thereby exacerbating psychiatric symptoms; and (4) clinicians often erroneously diagnose obstructive lung disease in patients with obesity hypoventilation, thereby exposing them to unnecessary and potentially harmful medications, including β-agonists and corticosteroids. Just as literary descriptions of pickwickian syndrome have given way to greater understanding of the pathophysiology of obesity hypoventilation, clinicians might exercise caution to consider these potential pitfalls and thus avoid inflicting unintended and avoidable complications.
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Pouwels S, Smeenk FW, Manschot L, Lascaris B, Nienhuijs S, Bouwman RA, Buise MP. Perioperative respiratory care in obese patients undergoing bariatric surgery: Implications for clinical practice. Respir Med 2016; 117:73-80. [DOI: 10.1016/j.rmed.2016.06.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2015] [Revised: 04/19/2016] [Accepted: 06/06/2016] [Indexed: 12/16/2022]
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Chung F, Abdullah HR, Liao P. STOP-Bang Questionnaire. Chest 2016; 149:631-8. [DOI: 10.1378/chest.15-0903] [Citation(s) in RCA: 542] [Impact Index Per Article: 67.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2015] [Revised: 08/19/2015] [Accepted: 08/22/2015] [Indexed: 01/14/2023] Open
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Manuel AR, Hart N, Stradling JR. Correlates of obesity-related chronic ventilatory failure. BMJ Open Respir Res 2016; 3:e000110. [PMID: 26918192 PMCID: PMC4762144 DOI: 10.1136/bmjresp-2015-000110] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 12/08/2015] [Accepted: 12/11/2015] [Indexed: 12/12/2022] Open
Abstract
Introduction Only a third of obese patients develop chronic ventilatory failure. This cross-sectional study assessed multiple factors potentially associated with chronic ventilatory failure. Materials/patients and methods Participants had a body mass index (BMI) >30 kg/m2, with or without chronic ventilatory failure (awake arterial partial pressure of carbon dioxide >6 kPa or base excess (BE) ≥2 mmols/L). Factors investigated were grouped into domains: (1) obesity measures, (2) pulmonary function, (3) respiratory and non-respiratory muscle strength, (4) sleep study derivatives, (5) hypoxic and hypercapnic responses, and (6) some hormonal, nutritional and inflammatory measures. Results 71 obese participants (52% male) were studied over 27 months, 52 (SD 9) years and BMI 47 (range 32–74) kg/m2. The best univariate correlates of BE from each domain were: (1) dual-energy X-ray absorptiometry measurement of visceral fat (r=+0.50, p=0.001); (2) supine forced expiratory volume in 1 s (r=−0.40, p=0.001); (3) sniff maximum pressure (r=−0.28, p=0.02); (4) mean overnight arterial oxygen saturation (r=−0.50, p<0.001); (5) ventilatory response to 15% O2 breathing (r=−0.28, p=0.02); and (6) vitamin D (r=−0.30, p=0.01). In multivariate analysis, only visceral fat and ventilatory response to hypoxia remained significant. Conclusions We have confirmed that in the obese, BMI is a poor correlate of chronic ventilatory failure, and the best independent correlates are visceral fat and hypoxic ventilatory response. Trial registration number NCT01380418.
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Affiliation(s)
- Ari R Manuel
- Oxford Centre for Respiratory Medicine, NIHR Oxford Biomedical Research Centre, Oxford University Churchill Campus, and Oxford University Hospitals NHS Trust , Oxford , UK
| | - Nicholas Hart
- Lane Fox Clinical Respiratory Physiology Centre, St Thomas' Hospital, Guy's & St Thomas' NHS Foundation Trust , London , UK
| | - John R Stradling
- Oxford Centre for Respiratory Medicine, NIHR Oxford Biomedical Research Centre, Oxford University Churchill Campus, and Oxford University Hospitals NHS Trust , Oxford , UK
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Palen BN, Kapur VK. Tailoring Therapy for Obesity Hypoventilation Syndrome. Am J Respir Crit Care Med 2015; 192:8-10. [PMID: 26131989 DOI: 10.1164/rccm.201504-0721ed] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Affiliation(s)
- Brian N Palen
- 1 Division of Pulmonary and Critical Care Medicine University of Washington Seattle, Washington and.,2 Veterans Affairs Puget Sound Health Care System Seattle, Washington
| | - Vishesh K Kapur
- 1 Division of Pulmonary and Critical Care Medicine University of Washington Seattle, Washington and
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Mohr MA, Fairchild KD, Patel M, Sinkin RA, Clark MT, Moorman JR, Lake DE, Kattwinkel J, Delos JB. Quantification of periodic breathing in premature infants. Physiol Meas 2015; 36:1415-27. [PMID: 26012526 DOI: 10.1088/0967-3334/36/7/1415] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Periodic breathing (PB), regular cycles of short apneic pauses and breaths, is common in newborn infants. To characterize normal and potentially pathologic PB, we used our automated apnea detection system and developed a novel method for quantifying PB. We identified a preterm infant who died of sudden infant death syndrome (SIDS) and who, on review of her breathing pattern while in the neonatal intensive care unit (NICU), had exaggerated PB.We analyzed the chest impedance signal for short apneic pauses and developed a wavelet transform method to identify repetitive 10-40 second cycles of apnea/breathing. Clinical validation was performed to distinguish PB from apnea clusters and determine the wavelet coefficient cutoff having optimum diagnostic utility. We applied this method to analyze the chest impedance signals throughout the entire NICU stays of all 70 infants born at 32 weeks' gestation admitted over a two-and-a-half year period. This group includes an infant who died of SIDS and her twin.For infants of 32 weeks' gestation, the fraction of time spent in PB peaks 7-14 d after birth at 6.5%. During that time the infant that died of SIDS spent 40% of each day in PB and her twin spent 15% of each day in PB.This wavelet transform method allows quantification of normal and potentially pathologic PB in NICU patients.
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Affiliation(s)
- Mary A Mohr
- Department of Physics, College of William and Mary, Williamsburg, VA 23187-8795, USA
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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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Palen BN, Swenson ER. Is a Raised Eucapnic Blood Bicarbonate Value a Bellwether of Preclinical Obesity Hypoventilation Syndrome? Chest 2015; 147:282-284. [DOI: 10.1378/chest.14-1970] [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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Kato T, Suda S, Kasai T. Positive airway pressure therapy for heart failure. World J Cardiol 2014; 6:1175-91. [PMID: 25429330 PMCID: PMC4244615 DOI: 10.4330/wjc.v6.i11.1175] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Revised: 07/16/2014] [Accepted: 09/18/2014] [Indexed: 02/06/2023] Open
Abstract
Heart failure (HF) is a life-threatening disease and is a growing public health concern. Despite recent advances in pharmacological management for HF, the morbidity and mortality from HF remain high. Therefore, non-pharmacological approaches for HF are being developed. However, most non-pharmacological approaches are invasive, have limited indication and are considered only for advanced HF. Accordingly, the development of less invasive, non-pharmacological approaches that improve outcomes for patients with HF is important. One such approach may include positive airway pressure (PAP) therapy. In this review, the role of PAP therapy applied through mask interfaces in the wide spectrum of HF care is discussed.
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Affiliation(s)
- Takao Kato
- Takao Kato, Department of Cardiology, Juntendo University School of Medicine, Tokyo 113-8421, Japan
| | - Shoko Suda
- Takao Kato, Department of Cardiology, Juntendo University School of Medicine, Tokyo 113-8421, Japan
| | - Takatoshi Kasai
- Takao Kato, Department of Cardiology, Juntendo University School of Medicine, Tokyo 113-8421, Japan
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Hillman D, Singh B, McArdle N, Eastwood P. Relationships between ventilatory impairment, sleep hypoventilation and type 2 respiratory failure. Respirology 2014; 19:1106-16. [PMID: 25219542 DOI: 10.1111/resp.12376] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2014] [Revised: 07/18/2014] [Accepted: 07/20/2014] [Indexed: 01/25/2023]
Affiliation(s)
- David Hillman
- Department of Pulmonary Physiology and Sleep Medicine; Sir Charles Gairdner Hospital; Perth Western Australia Australia
- West Australian Sleep Disorders Research Institute; Sir Charles Gairdner Hospital; Perth Western Australia Australia
- Centre for Sleep Science; School of Anatomy, Physiology and Human Biology; University of Western Australia; Perth Western Australia Australia
| | - Bhajan Singh
- Department of Pulmonary Physiology and Sleep Medicine; Sir Charles Gairdner Hospital; Perth Western Australia Australia
- West Australian Sleep Disorders Research Institute; Sir Charles Gairdner Hospital; Perth Western Australia Australia
| | - Nigel McArdle
- Department of Pulmonary Physiology and Sleep Medicine; Sir Charles Gairdner Hospital; Perth Western Australia Australia
- West Australian Sleep Disorders Research Institute; Sir Charles Gairdner Hospital; Perth Western Australia Australia
- Centre for Sleep Science; School of Anatomy, Physiology and Human Biology; University of Western Australia; Perth Western Australia Australia
| | - Peter Eastwood
- Department of Pulmonary Physiology and Sleep Medicine; Sir Charles Gairdner Hospital; Perth Western Australia Australia
- West Australian Sleep Disorders Research Institute; Sir Charles Gairdner Hospital; Perth Western Australia Australia
- Centre for Sleep Science; School of Anatomy, Physiology and Human Biology; University of Western Australia; Perth Western Australia Australia
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Abstract
Restrictive lung disease leads to ventilatory defects and diffusion impairments. These changes may contribute to abnormal nocturnal pathophysiology, including sleep architecture disruption and impaired ventilation and oxygenation. Patients with restrictive lung disease may suffer significant daytime fatigue and dysfunction. Hypercarbia and hypoxemia during sleep may impact progression of lung disease and related symptoms. Little is known about the impact of treatment of sleep disruption on sleep quality and overall prognosis in restrictive lung disease. This review discusses the pathophysiology of sleep and comorbid sleep disorders in restrictive lung diseases including interstitial lung disease, neuromuscular disease, and obesity hypoventilation syndrome.
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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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Piper A. Obesity hypoventilation syndrome: therapeutic implications for treatment. Expert Rev Respir Med 2014; 4:57-70. [DOI: 10.1586/ers.09.64] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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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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Abstract
This paper describes the interactions between ventilation and acid-base balance under a variety of conditions including rest, exercise, altitude, pregnancy, and various muscle, respiratory, cardiac, and renal pathologies. We introduce the physicochemical approach to assessing acid-base status and demonstrate how this approach can be used to quantify the origins of acid-base disorders using examples from the literature. The relationships between chemoreceptor and metaboreceptor control of ventilation and acid-base balance summarized here for adults, youth, and in various pathological conditions. There is a dynamic interplay between disturbances in acid-base balance, that is, exercise, that affect ventilation as well as imposed or pathological disturbances of ventilation that affect acid-base balance. Interactions between ventilation and acid-base balance are highlighted for moderate- to high-intensity exercise, altitude, induced acidosis and alkalosis, pregnancy, obesity, and some pathological conditions. In many situations, complete acid-base data are lacking, indicating a need for further research aimed at elucidating mechanistic bases for relationships between alterations in acid-base state and the ventilatory responses.
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Affiliation(s)
- Michael I Lindinger
- Department of Human Health and Nutritional Sciences, University of Guelph, Guelph, Ontario, Canada.
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42
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Verbraecken J, McNicholas WT. Respiratory mechanics and ventilatory control in overlap syndrome and obesity hypoventilation. Respir Res 2013; 14:132. [PMID: 24256627 PMCID: PMC3871022 DOI: 10.1186/1465-9921-14-132] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Accepted: 11/15/2013] [Indexed: 02/07/2023] Open
Abstract
The overlap syndrome of obstructive sleep apnoea (OSA) and chronic obstructive pulmonary disease (COPD), in addition to obesity hypoventilation syndrome, represents growing health concerns, owing to the worldwide COPD and obesity epidemics and related co-morbidities. These disorders constitute the end points of a spectrum with distinct yet interrelated mechanisms that lead to a considerable health burden. The coexistence OSA and COPD seems to occur by chance, but the combination can contribute to worsened symptoms and oxygen desaturation at night, leading to disrupted sleep architecture and decreased sleep quality. Alveolar hypoventilation, ventilation-perfusion mismatch and intermittent hypercapnic events resulting from apneas and hypopneas contribute to the final clinical picture, which is quite different from the “usual” COPD. Obesity hypoventilation has emerged as a relatively common cause of chronic hypercapnic respiratory failure. Its pathophysiology results from complex interactions, among which are respiratory mechanics, ventilatory control, sleep-disordered breathing and neurohormonal disturbances, such as leptin resistance, each of which contributes to varying degrees in individual patients to the development of obesity hypoventilation. This respiratory embarrassment takes place when compensatory mechanisms like increased drive cannot be maintained or become overwhelmed. Although a unifying concept for the pathogenesis of both disorders is lacking, it seems that these patients are in a vicious cycle. This review outlines the major pathophysiological mechanisms believed to contribute to the development of these specific clinical entities. Knowledge of shared mechanisms in the overlap syndrome and obesity hypoventilation may help to identify these patients and guide therapy.
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Affiliation(s)
- Johan Verbraecken
- Department of Pulmonary Medicine and Multidisciplinary Sleep Disorders Centre, Antwerp University Hospital and University of Antwerp, Wilrijkstraat 10, Edegem 2650, Belgium.
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Priou P, Trzepizur W, Gagnadoux F. Le syndrome obésité-hypoventilation: revue de la littérature. MEDECINE INTENSIVE REANIMATION 2013. [DOI: 10.1007/s13546-013-0697-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Hart N, Mandal S, Manuel A, Mokhlesi B, Pépin JL, Piper A, Stradling JR. Obesity hypoventilation syndrome: does the current definition need revisiting? Thorax 2013; 69:83-4. [PMID: 23986390 DOI: 10.1136/thoraxjnl-2013-204298] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Nicholas Hart
- Lane Fox Unit and Critical Care, St Thomas' Hospital, , London, UK
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Chung F, Chau E, Yang Y, Liao P, Hall R, Mokhlesi B. Serum Bicarbonate Level Improves Specificity of STOP-Bang Screening for Obstructive Sleep Apnea. Chest 2013; 143:1284-1293. [DOI: 10.1378/chest.12-1132] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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46
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Brown LK. Noninvasive ventilatory support in obesity hypoventilation syndrome: backup early and often? Chest 2013; 143:8-10. [PMID: 23276838 DOI: 10.1378/chest.12-1835] [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
Affiliation(s)
- Lee K Brown
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of New Mexico School of Medicine, and the Program in Sleep Medicine, University of New Mexico Health Sciences Center, Albuquerque, NM.
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Affiliation(s)
- Edmond H.L. Chau
- Department of Anesthesiology, Toronto Western Hospital, University Health Network, University of Toronto, Bathurst Street, Toronto, Ontario M5T2S8, Canada
| | - Babak Mokhlesi
- Section of Pulmonary and Critical Care Medicine, Department of Medicine, Sleep Disorders Center, University of Chicago Pritzker School of Medicine, Maryland Avenues, Chicago, IL 60637, USA
| | - Frances Chung
- Department of Anesthesiology, Toronto Western Hospital, University Health Network, University of Toronto, Bathurst Street, Toronto, Ontario M5T2S8, Canada
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BOREL JEANCHRISTIAN, BOREL ANNELAURE, MONNERET DENIS, TAMISIER RENAUD, LEVY PATRICK, PEPIN JEANLOUIS. Obesity hypoventilation syndrome: From sleep-disordered breathing to systemic comorbidities and the need to offer combined treatment strategies. Respirology 2012; 17:601-10. [DOI: 10.1111/j.1440-1843.2011.02106.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Abstract
The hypoventilation syndromes represent a variety of disorders that affect central ventilatory control, respiratory mechanics, or both. Obesity hypoventilation syndrome is a clinically important disorder with serious cardiovascular and metabolic consequences if unrecognized. Hypoventilation in asthma and COPD is caused by mechanical challenges imparted by airflow obstruction and increase in dead space. In neuromuscular disease, respiratory muscle weakness results in hypoventilation. Decreases in thoracic volume and limited expansion of the chest highlight the restrictive ventilatory impairments seen in hypoventilation associated with chest wall disorders. Despite the mechanism, effective hypoventilation treatment targets the underlying disease and use of noninvasive ventilation.
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Affiliation(s)
- Ahmad Chebbo
- Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Scott and White Healthcare/Texas A&M Health Science Center, Temple, TX 76508, USA
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