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Aung O, Amorim MR, Mendelowitz D, Polotsky VY. Revisiting the Role of Serotonin in Sleep-Disordered Breathing. Int J Mol Sci 2024; 25:1483. [PMID: 38338762 PMCID: PMC10855456 DOI: 10.3390/ijms25031483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 01/22/2024] [Accepted: 01/24/2024] [Indexed: 02/12/2024] Open
Abstract
Serotonin or 5-hydroxytryptamine (5-HT) is a ubiquitous neuro-modulator-transmitter that acts in the central nervous system, playing a major role in the control of breathing and other physiological functions. The midbrain, pons, and medulla regions contain several serotonergic nuclei with distinct physiological roles, including regulating the hypercapnic ventilatory response, upper airway patency, and sleep-wake states. Obesity is a major risk factor in the development of sleep-disordered breathing (SDB), such as obstructive sleep apnea (OSA), recurrent closure of the upper airway during sleep, and obesity hypoventilation syndrome (OHS), a condition characterized by daytime hypercapnia and hypoventilation during sleep. Approximately 936 million adults have OSA, and 32 million have OHS worldwide. 5-HT acts on 5-HT receptor subtypes that modulate neural control of breathing and upper airway patency. This article reviews the role of 5-HT in SDB and the current advances in 5-HT-targeted treatments for SDB.
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Affiliation(s)
- O Aung
- Department of Medicine, Johns Hopkins University, Baltimore, MD 21224, USA; (O.A.); (M.R.A.)
- Medical College of Wisconsin, Milwaukee, WI 53226, USA
- Department of Anesthesiology and Critical Care Medicine, George Washington University, Washington, DC 20037, USA
| | - Mateus R. Amorim
- Department of Medicine, Johns Hopkins University, Baltimore, MD 21224, USA; (O.A.); (M.R.A.)
- Department of Anesthesiology and Critical Care Medicine, George Washington University, Washington, DC 20037, USA
| | - David Mendelowitz
- Department of Pharmacology and Physiology, George Washington University, Washington, DC 20037, USA;
| | - Vsevolod Y. Polotsky
- Department of Medicine, Johns Hopkins University, Baltimore, MD 21224, USA; (O.A.); (M.R.A.)
- Department of Anesthesiology and Critical Care Medicine, George Washington University, Washington, DC 20037, USA
- Department of Pharmacology and Physiology, George Washington University, Washington, DC 20037, USA;
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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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Herkenrath SD, Treml M, Hagmeyer L, Matthes S, Randerath WJ. Severity stages of obesity-related breathing disorders - a cross-sectional cohort study. Sleep Med 2022; 90:9-16. [PMID: 35051737 DOI: 10.1016/j.sleep.2021.12.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 12/22/2021] [Accepted: 12/27/2021] [Indexed: 11/16/2022]
Abstract
INTRODUCTION There is a general underappreciation of the spectrum of obesity-related breathing disorders and their consequences. We therefore compared characteristics of obese patients with eucapnic obstructive sleep apnea (OSA), OSA with obesity-related sleep hypoventilation (ORSH) or obesity hypoventilation syndrome (OHS) to identify the major determinants of hypoventilation. PATIENTS AND METHODS In this prospective, diagnostic study (NCT04570540), obese patients with OSA, ORSH or OHS were characterized applying polysomnography with transcutaneous capnometry, blood gas analyses, bodyplethysmography and measurement of hypercapnic ventilatory response (HCVR). Pathophysiological variables known to contribute to hypoventilation and differing significantly between the groups were specified as potential independent variables in a multivariable logistic regression to identify major determinants of hypoventilation. RESULTS Twenty, 43 and 19 patients were in the OSA, ORSH and OHS group, respectively. BMI was significantly lower in OSA as compared to OHS. The extent of SRBD was significantly higher in OHS as compared to OSA or ORSH. Patients with ORSH or OHS showed a significantly decreased forced expiratory volume in 1 s and forced vital capacity compared to OSA. HCVR was significantly lower in OHS and identified as the major determinant of hypoventilation in a multivariable logistic regression (Nagelkerke R2 = 0.346, p = 0.050, odds ratio (95%-confidence interval) 0.129 (0.017-1.004)). CONCLUSION Although there were differences in BMI, respiratory mechanics and severity of upper airway obstruction between groups, our data support HCVR as the major determinant of obesity-associated hypoventilation.
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Affiliation(s)
- Simon D Herkenrath
- Bethanien Hospital, Clinic for Pneumology and Allergology, Center for Sleep Medicine and Respiratory Care, Solingen, Germany; Institute for Pneumology at the University of Cologne, Germany
| | - Marcel Treml
- Institute for Pneumology at the University of Cologne, Germany
| | - Lars Hagmeyer
- Bethanien Hospital, Clinic for Pneumology and Allergology, Center for Sleep Medicine and Respiratory Care, Solingen, Germany; Institute for Pneumology at the University of Cologne, Germany
| | - Sandhya Matthes
- Bethanien Hospital, Clinic for Pneumology and Allergology, Center for Sleep Medicine and Respiratory Care, Solingen, Germany
| | - Winfried J Randerath
- Bethanien Hospital, Clinic for Pneumology and Allergology, Center for Sleep Medicine and Respiratory Care, Solingen, Germany; Institute for Pneumology at the University of Cologne, Germany.
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BaHammam AS, Aleissi SA, Nashwan SZ, Olaish AH, Almeneessier AS. Results of CPAP Titration and Short-Term Adherence Rates in Patients with Obesity Hypoventilation Syndrome and Mild/Moderate Obstructive Sleep Apnea. Nat Sci Sleep 2022; 14:1137-1148. [PMID: 35733818 PMCID: PMC9207127 DOI: 10.2147/nss.s369316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 06/09/2022] [Indexed: 11/23/2022] Open
Abstract
PURPOSE No study has assessed the titration success of CPAP therapy in patients with obesity hypoventilation syndrome (OHS) and an apnea-hypopnea index (AHI) <30 event/h. This study aimed to assess the titration success of CPAP therapy under polysomnography and subsequent short-term adherence (1 month) in patients with OHS and an AHI <30 event/h. METHODS Consecutive OHS patients with an AHI <30 events/h between 2010 and 2019 were included (n=54). All OHS patients were first started on CPAP during the therapeutic sleep-study. If the therapeutic-study showed that the SpO2 remained < 90% for 20% of the total sleep time, a second therapeutic study was arranged with bi-level PAP (BPAP). Thirty patients agreed to participate in the 1-month follow-up adherence study. We applied the American-Thoracic-Society criteria for PAP adherence. RESULTS The mean age was 54.8±14.6 years, and the mean BMI was 45.9±12.2 kg/m2. Successful titration on CPAP was attained in 36 (66.7%) patients, and 18 (33.3%) required BPAP. Patients who failed the CPAP trial had a significantly higher PaCO2 and bicarbonate, a more restrictive respiratory pattern on spirometry, and a significantly higher time with SpO2<90% (mins) during sleep. The only independent correlate of CPAP-titration success on the multivariable regression analysis was the desaturation index (OR: 1.33 [1.033-1.712]). More than 80% of the participants were using CPAP therapy after one-month with no differences in adherence between the CPAP and BPAP groups. CONCLUSIONS The current results suggest that CPAP therapy could be an acceptable alternative therapy to BPAP in patients with OHS without severe OSA.
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Affiliation(s)
- Ahmed S BaHammam
- The University Sleep Disorders Center, Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Salih A Aleissi
- The University Sleep Disorders Center, Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Samar Z Nashwan
- The University Sleep Disorders Center, Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Awad H Olaish
- The University Sleep Disorders Center, Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Aljohara S Almeneessier
- The University Sleep Disorders Center, Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia.,Department of Family and Community Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Lastra AC, Masa JF, Mokhlesi B. CPAP titration failure is not equivalent to long-term CPAP treatment failure in patients with obesity hypoventilation syndrome: a case series. J Clin Sleep Med 2021; 16:1975-1981. [PMID: 32713421 DOI: 10.5664/jcsm.8712] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
STUDY OBJECTIVES Medium and long-term trials comparing continuous positive airway pressure (CPAP) with noninvasive ventilation in patients with obesity hypoventilation syndrome have shown no differences in outcomes. However, it remains unclear whether CPAP therapy should be prescribed if significant hypoxemia persists during CPAP titration, despite optimization of upper airway obstructive events or if maximum CPAP pressure is reached. We aimed to examine the effects of 6 weeks of home CPAP therapy on gas exchange in patients with obesity hypoventilation syndrome who failed CPAP titration due to persistent hypoxemia. METHODS This case series is a substudy of a randomized-controlled trial evaluating efficacy of 3 different PAP modalities in obesity hypoventilation syndrome. Patients randomized to CPAP who failed titration and were prescribed CPAP are included. CPAP failure was defined as spending more than 20% of total sleep time with oxygen saturation below 90% despite adequate resolution of apneas and hypopneas. Follow-up data included in-laboratory polysomnogram on prescribed CPAP after 6 weeks of home CPAP therapy. RESULTS Three of seven participants (43%) randomized to CPAP failed CPAP titration. All were morbidly obese, had severe OSA (apnea-hypopnea index > 90 events/h) and severe sleep hypoxemia (percentage of total sleep time with oxygen saturation < 90% [T90] = 60-89%). Hypoxemia (T90: 43-67%, T80: 0-31%, and T70: 0-11%) and hypercapnia (transcutaneous pressure of CO₂ levels > 50 mm Hg) persisted during CPAP titration polysomnogram. The final polysomnogram after 6 weeks of adherent home CPAP therapy showed effective control of obstructive sleep apnea. Hypoventilation and hypoxemia severity decreased significantly in all 3 participants. CONCLUSIONS Our data suggest that CPAP titration failure does not equal CPAP treatment failure. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Name: AVAPS-AE Efficacy Study; URL: https://clinicaltrials.gov/ct2/show/NCT01368614; Identifier: NCT01368614.
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Affiliation(s)
- Alejandra C Lastra
- Division of Pulmonary, Critical Care and Sleep Medicine, Rush University Medical Center, Chicago, Illinois
| | - Juan F Masa
- Respiratory Department, San Pedro de Alcántara Hospital, Cáceres, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Babak Mokhlesi
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, Illinois
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Arellano-Maric MP, Hamm C, Duiverman ML, Schwarz S, Callegari J, Storre JH, Schmoor C, Spielmanns M, Galetke W, Windisch W. Obesity hypoventilation syndrome treated with non-invasive ventilation: Is a switch to CPAP therapy feasible? Respirology 2019; 25:435-442. [PMID: 31597227 DOI: 10.1111/resp.13704] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 08/20/2019] [Accepted: 09/03/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVE Obesity hypoventilation syndrome (OHS) can be treated with either continuous positive airway pressure (CPAP) or non-invasive ventilation (NIV) therapy; the device choice has important economic and operational implications. METHODS This multicentre interventional trial investigated the safety and short-term efficacy of switching stable OHS patients who were on successful NIV therapy for ≥3 months to CPAP therapy. Patients underwent an autotitrating CPAP night under polysomnography (PSG); if the ensuing parameters were acceptable, they were sent home on a fixed CPAP for a 4-6-week period. It was hypothesized that blood gas analysis, PSG parameters and lung function tests would remain unchanged. RESULTS A total of 42 OHS patients were recruited, of whom 37 patients were switched to CPAP therapy. All patients had a history of severe obstructive sleep apnoea syndrome; chronic obstructive pulmonary disease (COPD) (Global Initiative for Obstructive Lung Disease (GOLD) I/II) was present in 52%. Regarding the primary outcome, 30 of 42 patients (71%, 95% CI: 55-84%) maintained daytime partial pressure of carbon dioxide (PaCO2 ) levels ≤45 mm Hg after the home CPAP period. There was no further impairment in quality of life, sleep parameters or lung function. Interestingly, 24 patients (65%) preferred CPAP as their long-term therapy, despite the high pressure levels used (mean: 13.8 ± 1.8 mbar). After the CPAP period, 7 of 37 patients were categorized as CPAP failure, albeit only due to mild hypercapnia (mean: 47.9 ± 2.7 mm Hg). CONCLUSION It is feasible to switch most stable OHS patients from NIV to CPAP therapy, a step that could significantly reduce health-related costs. The auto-adjusted CPAP device, used in combination with the analysis of the PSG and capnometry, is a valid titration method in OHS patients.
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Affiliation(s)
- Maria P Arellano-Maric
- Department of Pneumology, Cologne Merheim Hospital, Kliniken der Stadt Köln, Germany.,Department of Pneumology, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Christine Hamm
- Department of Pneumology, Cologne Merheim Hospital, Kliniken der Stadt Köln, Germany.,Faculty of Health/School of Medicine, Witten/Herdecke University, Cologne, Germany
| | - Marieke L Duiverman
- Department of Pulmonary Diseases/Home Mechanical Ventilation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Groningen Research Institute of Asthma and COPD, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Sarah Schwarz
- Department of Pneumology, Cologne Merheim Hospital, Kliniken der Stadt Köln, Germany.,Faculty of Health/School of Medicine, Witten/Herdecke University, Cologne, Germany
| | - Jens Callegari
- Department of Pneumology, Cologne Merheim Hospital, Kliniken der Stadt Köln, Germany.,Faculty of Health/School of Medicine, Witten/Herdecke University, Cologne, Germany
| | - Jan H Storre
- Department of Intensive Care, Sleep Medicine and Mechanical Ventilation, Asklepios, Fachkliniken Munich-Gauting, Gauting, Germany.,Department of Pneumology, University Medical Center Freiburg, Freiburg, Germany
| | - Claudia Schmoor
- Clinical Trials Center, University Medical Center, Freiburg, Germany
| | - Marc Spielmanns
- Faculty of Health/School of Medicine, Witten/Herdecke University, Cologne, Germany.,Department of Pneumology, St. Remigius Hospital, Opladen, Germany
| | - Wolfgang Galetke
- Department of Pneumology, Hospital der Augustinerinnen, Cologne, Germany
| | - Wolfram Windisch
- Department of Pneumology, Cologne Merheim Hospital, Kliniken der Stadt Köln, Germany.,Faculty of Health/School of Medicine, Witten/Herdecke University, Cologne, Germany
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An act of balance: Interaction of central and peripheral chemosensitivity with inflammatory and anti-inflammatory factors in obstructive sleep apnoea. Respir Physiol Neurobiol 2019; 266:73-81. [DOI: 10.1016/j.resp.2019.05.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Revised: 04/30/2019] [Accepted: 05/02/2019] [Indexed: 02/05/2023]
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Fernández Álvarez R, Rubinos Cuadrado G, Ruiz Alvarez I, Hermida Valverde T, Iscar Urrutia M, Vázquez Lopez MJ, Casan Clara P. Respuesta a la hipercapnia en pacientes con síndrome obesidad-hipoventilación en tratamiento con ventilación no invasiva en domicilio. Arch Bronconeumol 2018; 54:455-459. [DOI: 10.1016/j.arbres.2018.03.023] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Revised: 02/09/2018] [Accepted: 03/05/2018] [Indexed: 11/16/2022]
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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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Shoukri A. Study of the value of percutaneous nocturnal oximetry in the monitoring of obese hypoventilation syndrome patients under non invasive home ventilation. THE EGYPTIAN JOURNAL OF BRONCHOLOGY 2017. [DOI: 10.4103/1687-8426.199005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] 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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12
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Ortiz VE, Kwo J. Obesity: physiologic changes and implications for preoperative management. BMC Anesthesiol 2015; 15:97. [PMID: 26141622 PMCID: PMC4491231 DOI: 10.1186/s12871-015-0079-8] [Citation(s) in RCA: 45] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2014] [Accepted: 06/24/2015] [Indexed: 02/08/2023] Open
Abstract
The proportion of patients defined as obese continues to grow in many westernized nations, particularly the United States (USA). This trend has shifted the perioperative management of obese patients into the realm of routine care. As obese patients present for all types of procedures, it is crucial for anesthesiologists, surgeons, internists, and perioperative health care providers alike to have a firm understanding of their altered multi-organ physiology in order to safely prepare the obese patient for an operation. A careful preoperative evaluation may also serve to identify risk factors for postoperative adverse events. Subsequently, preoperative measures may be implemented to mitigate these complications. In this manuscript we address the major considerations for the preoperative evaluation of the severely obese patient.
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Affiliation(s)
- Vilma E Ortiz
- Department of Anesthesia, Critical Care & Pain Medicine, Associate Anesthetist, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
| | - Jean Kwo
- Department of Anesthesia, Critical Care & Pain Medicine, Associate Anesthetist, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA.
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Abstract
This article summarizes available data on the obesity hypoventilation syndrome and its pertinence to intensivists, outlines clinical and pathophysiologic aspects of the disease, discusses multidisciplinary treatments, and reviews the available literature on outcomes specific to the critically ill patient.
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Affiliation(s)
- Shirley F Jones
- Division of Pulmonary Critical Care and Sleep Medicine, Department of Medicine, Baylor Scott &White Health, Texas A&M Health Science Center, 2401 South 31st Street, Temple, TX 76508, USA.
| | - Veronica Brito
- Division of Pulmonary Critical Care and Sleep Medicine, Department of Medicine, Baylor Scott &White Health, Texas A&M Health Science Center, 2401 South 31st Street, Temple, TX 76508, USA
| | - Shekhar Ghamande
- Division of Pulmonary Critical Care and Sleep Medicine, Department of Medicine, Baylor Scott &White Health, Texas A&M Health Science Center, 2401 South 31st Street, Temple, TX 76508, USA
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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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Ortiz VE, Vidal-Melo MF, Walsh JL. Strategies for managing oxygenation in obese patients undergoing laparoscopic surgery. Surg Obes Relat Dis 2014; 11:721-8. [PMID: 25863532 DOI: 10.1016/j.soard.2014.11.021] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 10/29/2014] [Accepted: 11/27/2014] [Indexed: 12/17/2022]
Abstract
The worldwide trend toward increasing body mass index (BMI) has caused the anesthetic management of overweight, obese, and severely obese patients to become common. The increase in oxygen demand coupled with the anatomic and physiologic changes associated with excess adipose tissue make maintenance of oxygenation a major challenge during induction, maintenance and recovery from general anesthesia. It is crucial for anesthesiologists, surgeons and perioperative healthcare providers alike to have a thorough understanding of the impact of airway management and mechanical ventilation on the respiratory care of the obese in the immediate perioperative setting. In this manuscript we aim to discuss the consequences of obesity, particularly abdominal obesity, on respiratory physiology and provide suggestions on intraoperative ventilatory strategies to maintain oxygenation in the severely obese patient undergoing pneumoperitoneum.
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Affiliation(s)
- Vilma E Ortiz
- Massachusetts General Hospital, Department of Anesthesia, Critical Care & Pain Medicine, Boston, Massachusetts.
| | - Marcos F Vidal-Melo
- Massachusetts General Hospital, Department of Anesthesia, Critical Care & Pain Medicine, Boston, Massachusetts
| | - John L Walsh
- Massachusetts General Hospital, Department of Anesthesia, Critical Care & Pain Medicine, Boston, Massachusetts
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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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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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Esquinas AM, Petroianni A. Non-invasive mechanical ventilation in obesity hypoventilation syndrome: are multimodal therapeutic strategies disease essential? Respirology 2013; 18:385. [PMID: 23231633 DOI: 10.1111/resp.12027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Douglas RM, Bowden K, Pattison J, Peterson AB, Juliano J, Dalton ND, Gu Y, Alvarez E, Imamura T, Peterson KL, Witztum JL, Haddad GG, Li AC. Intermittent hypoxia and hypercapnia induce pulmonary artery atherosclerosis and ventricular dysfunction in low density lipoprotein receptor deficient mice. J Appl Physiol (1985) 2013; 115:1694-704. [PMID: 23990245 DOI: 10.1152/japplphysiol.00442.2013] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Patients with obstructive sleep apnea, who experience episodic hypoxia and hypercapnia during sleep, often demonstrate increased inflammation, oxidative stress, and dyslipidemia. We hypothesized that sleep apnea patients would be predisposed to the development of atherosclerosis. To dissect the mechanisms involved, we developed an animal model in mice whereby we expose mice to intermittent hypoxia/hypercapnia (IHH) in normobaric environments. Two- to three-month-old low-density lipoprotein receptor deficient (Ldlr(-/-)) mice were fed a high-fat diet for 8 or 16 wk while being exposed to IHH for either 10 h/day or 24 h/day. Plasma lipid levels, pulmonary artery and aortic atherosclerotic lesions, and cardiac function were then assayed. Surprisingly, atherosclerosis in the aorta of IHH mice was similar compared with controls. However, in IHH mice, atherosclerosis was markedly increased in the trunk and proximal branches of the pulmonary artery of exposed mice; even though plasma cholesterol and triglycerides were lower than in controls. Hemodynamic analysis revealed that right ventricular maximum pressure and isovolumic relaxation constant were significantly increased in IHH exposed mice and left ventricular % fractional shortening was reduced. In conclusion, 1) Intermittent hypoxia/hypercapnia remarkably accelerated atherosclerotic lesions in the pulmonary artery of Ldlr(-/-) mice and 2) increased lesion formation in the pulmonary artery was associated with right and left ventricular dysfunction. These findings raise the possibility that patients with obstructive sleep apnea may be susceptible to atherosclerotic disease in the pulmonary vasculature, an observation that has not been previously recognized.
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Affiliation(s)
- Robert M Douglas
- Department of Pediatrics, University of California, San Diego, La Jolla, California
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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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Affiliation(s)
- Fang Han
- Department of Respiratory Medicine, The Peking University People's Hospital, Beijing, China.
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Measurement of dyspnea in patients with obstructive sleep apnea. Sleep Breath 2012; 17:753-61. [DOI: 10.1007/s11325-012-0759-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Revised: 07/09/2012] [Accepted: 07/23/2012] [Indexed: 01/22/2023]
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Borel JC, Tamisier R, Gonzalez-Bermejo J, Baguet JP, Monneret D, Arnol N, Roux-Lombard P, Wuyam B, Levy P, Pépin JL. Noninvasive ventilation in mild obesity hypoventilation syndrome: a randomized controlled trial. Chest 2011; 141:692-702. [PMID: 21885724 DOI: 10.1378/chest.10-2531] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
OBJECTIVE Open studies suggest that treatment of obesity hypoventilation syndrome (OHS) by noninvasive ventilation (NIV) restores sleep quality and daytime vigilance and reduces cardiovascular morbidity. However, to our knowledge no randomized controlled trial (RCT) comparing NIV to conservative measures is available in the field. The goal of this study was to assess in patients with OHS, during an RCT, effects of 1-month NIV compared with lifestyle counseling on blood gas measurements, sleep quality, vigilance, and cardiovascular, metabolic, and inflammatory parameters. METHODS Thirty-five patients in whom OHS was newly diagnosed were randomized either to the NIV group or the control group represented by lifestyle counseling. Assessments included blood gas levels, subjective daytime sleepiness, metabolic parameters, inflammatory (hsCRP, leptin, regulated upon activation normal T-cell express and secreted [RANTES], monocyte chemoattractant protein-1, IL-6, IL-8, tumor necrosis factor-α, resistin) and antiinflammatory (adiponectin, IL-1-RA) cytokines, sleep studies, endothelial function (reactive hyperemia measured by peripheral arterial tonometry [RH-PAT]), and arterial stiffness. RESULTS Despite randomization, NIV group patients (n = 18) were older (58 ± 11 years vs 54 ± 6 years) with a higher baseline Paco(2) (47.9 ± 4.2 mm Hg vs 45.2 ± 3 mm Hg). In intention-to-treat analysis, compared with control group, NIV treatment significantly reduced daytime Paco(2) (difference between treatments: -3.5 mm Hg; 95% CI, -6.2 to -0.8) and apnea-hypopnea index (-40.3/h; 95% CI, -62.4 to -18.2). Sleep architecture was restored, although nonrespiratory microarousals increased (+9.4/h of sleep; 95% CI, 1.9-16.9), and daytime sleepiness was not completely normalized. Despite a dramatic improvement in sleep hypoxemia, glucidic and lipidic metabolism parameters as well as cytokine profiles did not vary significantly. Accordingly, neither RH-PAT (+0.02; 95% CI, -0.24 to 0.29) nor arterial stiffness (+0.22 m/s; 95% CI, -1.47 to 1.92) improved. CONCLUSIONS One month of NIV treatment, although improving sleep and blood gas measurements dramatically, did not change inflammatory, metabolic, and cardiovascular markers. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT00603096; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Jean-Christian Borel
- INSERM 1042, HP2 Laboratory, Université Joseph Fourier, Faculté de Médecine, Grenoble
| | - Renaud Tamisier
- INSERM 1042, HP2 Laboratory, Université Joseph Fourier, Faculté de Médecine, Grenoble; Pôle Rééducation et Physiologie, CHU, Hôpital A. Michallon, Grenoble
| | - Jesus Gonzalez-Bermejo
- AP-HP, Groupe hospitalier Pitié-Salpêtrière, Service de Pneumologie et réanimation médicale, Paris
| | | | - Denis Monneret
- INSERM 1042, HP2 Laboratory, Université Joseph Fourier, Faculté de Médecine, Grenoble
| | - Nathalie Arnol
- INSERM 1042, HP2 Laboratory, Université Joseph Fourier, Faculté de Médecine, Grenoble; Pôle Rééducation et Physiologie, CHU, Hôpital A. Michallon, Grenoble
| | - Pascale Roux-Lombard
- Service d'Immunologie et d'Allergologie, Hôpitaux Universitaires et Université de Genève, Geneva, Switzerland
| | - Bernard Wuyam
- Pôle Rééducation et Physiologie, CHU, Hôpital A. Michallon, Grenoble
| | - Patrick Levy
- INSERM 1042, HP2 Laboratory, Université Joseph Fourier, Faculté de Médecine, Grenoble; Pôle Rééducation et Physiologie, CHU, Hôpital A. Michallon, Grenoble
| | - Jean-Louis Pépin
- INSERM 1042, HP2 Laboratory, Université Joseph Fourier, Faculté de Médecine, Grenoble; Pôle Rééducation et Physiologie, CHU, Hôpital A. Michallon, Grenoble.
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Wijesinghe M, Williams M, Perrin K, Weatherall M, Beasley R. The Effect of Supplemental Oxygen on Hypercapnia in Subjects With Obesity-Associated Hypoventilation. Chest 2011; 139:1018-1024. [DOI: 10.1378/chest.10-1280] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Rabec C, de Lucas Ramos P, Veale D. Respiratory complications of obesity. Arch Bronconeumol 2011; 47:252-61. [PMID: 21458904 DOI: 10.1016/j.arbres.2011.01.012] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2010] [Revised: 12/21/2010] [Accepted: 01/12/2011] [Indexed: 10/15/2022]
Abstract
Obesity, well known as a cardiovascular risk factor, can also lead to significant respiratory complications. The respiratory changes associated with obesity extend from a simple change in respiratory function, with no effect on gas exchange, to the more serious condition of hypercapnic respiratory failure, characteristic of obesity hypoventilation syndrome. More recently, it has been reported that there is an increased prevalence of asthma which is probably multifactorial in origin, but in which inflammation may play an important role. Hypoventilation in the obese subject is the result of complex interactions that involve changes in the ventilatory mechanics and anomalies in breathing control. Two other conditions (COPD and sleep apnea-hypopnea syndrome [SAHS], often present in obese patients, can trigger or aggravate it. The prevalence of hypoventilation in the obese is under-estimated and the diagnosis is usually established during an exacerbation, or when the patient is studied due to suspicion of SAHS. Ventilatory management of these patients includes either CPAP or NIV. The choice of one or another will depend on the underlying clinical condition and whether or not there is another comorbidity. Both NIV and CPAP have demonstrated their effectiveness, not only in the control of gas exchange, but also in improving the quality of life and survival of these patients.
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Affiliation(s)
- Claudio Rabec
- Service de Pneumologie et Réanimation Respiratoire, CHU Dijon, Francia.
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Respiratory regulation in narcolepsy. Sleep Breath 2011; 16:241-5. [PMID: 21318258 DOI: 10.1007/s11325-011-0489-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2010] [Revised: 01/17/2011] [Accepted: 01/24/2011] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Narcolepsy is a debilitating sleep disorder characterized by excessive daytime sleepiness, cataplexy and intrusive REM sleep. Deficits in endogenous orexins are a major pathogenic component of the disease. This disorder is also associated with the gene marker, HLADQB1*0602. An increased prevalence of sleep apnea in narcolepsy suggested interactions among ventilatory chemosensitivity, narcolepsy-cataplexy, and sleep apnea. RESULTS Evidence from animal studies using orexin knockout mice and focal microdialysis of an orexin receptor antagonist demostrated that orexins are also contributed to respiratory regulation in a vigilance state-dependent manner, as animals with orexins dysregulation have attenuated hypercapnic ventilatory responses predominately in wakefulness, which is consistent with the notion that the activity of orexinergic neurons is higher during wake than sleep periods. Human model of hypocretin deficiency is patients with narcolepsy-cataplexy. In contrast to findings suggested by animal studies, we found significant decrease in hypoxic responsiveness but not in hypercapnic responsiveness in narcoleptics, and further analysis indicated that decreased ventilatory responses to hypoxia in human narcolepsy-cataplexy is in relation to HLA-DQB1*0602 status, not hypocretin deficiency. CONCLUSION Unlike in mouse, hypocretin-1 is not a major factor contributing to chemoresponsiveness in human. Species differences may exist.
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Abstract
Obesity is becoming a major medical concern in several parts of the world, with huge economic impacts on health- care systems, resulting mainly from increased cardiovascular risks. At the same time, obesity leads to a number of sleep-disordered breathing patterns like obstructive sleep apnea and obesity hypoventilation syndrome (OHS), leading to increased morbidity and mortality with reduced quality of life. OHS is distinct from other sleep- related breathing disorders although overlap may exist. OHS patients may have obstructive sleep apnea/hypopnea with hypercapnia and sleep hypoventilation, or an isolated sleep hypoventilation. Despite its major impact on health, this disorder is under-recognized and under-diagnosed. Available management options include aggressive weight reduction, oxygen therapy and using positive airway pressure techniques. In this review, we will go over the epidemiology, pathophysiology, presentation and diagnosis and management of OHS.
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Affiliation(s)
- Laila Al Dabal
- Department of Pulmonary Medicine, Rashid Hospital, Dubai Health Authority, UAE
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Robert D, Argaud L. Noninvasive positive ventilation in the treatment of sleep-related breathing disorders. HANDBOOK OF CLINICAL NEUROLOGY 2010; 98:459-69. [PMID: 21056205 DOI: 10.1016/b978-0-444-52006-7.00030-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Dominique Robert
- Emergency and Intensive Care Department, Edoward Herriot Hopsital, Lyon, France.
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Abstract
Obesity-hypoventilation syndrome (OHS), also historically described as the Pickwickian syndrome, consists of the triad of obesity, sleep disordered breathing, and chronic hypercapnia during wakefulness in the absence of other known causes of hypercapnia. Its exact prevalence is unknown, but it has been estimated that 10% to 20% of obese patients with obstructive sleep apnea have hypercapnia. OHS often remains undiagnosed until late in the course of the disease. Early recognition is important because these patients have significant morbidity and mortality. Effective treatment can lead to significant improvement in patient outcomes, underscoring the importance of early diagnosis. The authors review the definition and epidemiology of OHS, in addition to the current multifaceted understanding of the pathophysiology, and provide useful clinical approaches to diagnosis and treatment.
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Affiliation(s)
- Stephen W Littleton
- Sleep Medicine Fellowship Program, Section of Pulmonary and Critical Care Medicine, University of Chicago, Room W438, Chicago, IL 60637, USA
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Kaw R, Hernandez AV, Walker E, Aboussouan L, Mokhlesi B. Determinants of Hypercapnia in Obese Patients With Obstructive Sleep Apnea. Chest 2009; 136:787-796. [DOI: 10.1378/chest.09-0615] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Abstract
Obesity, well-known as a cardiovascular risk factor is also a "respiratory" risk factor and can have profound adverse effects on the respiratory system, such as alterations in pulmonary function tests, respiratory mechanics, respiratory muscle strength and endurance, gas exchange, control of breathing and exercise capacity. ABG are frequently altered in obese subjects and abnormalities are directly proportional to BMI. Two main pathophysiological mechanisms may account for gas exchange abnormalities: V/Q inequality, responsible for isolated hypoxemia, and alveolar hypoventilation responsible for the also called "obesity hypoventilation syndrome" (OHS). Hypoventilation in obese patients includes a diversity of mechanisms frequently imbricated, among which the two most frequent are mechanical limitation and blunted ventilatory drive. Two other clinical entities (COPD and OSA) frequently present in the obese patients may potentiate or aggravate this hypoventilation. OHS is frequently underappreciated and diagnosis is rarely made at the steady state. Such diagnosis is frequently made in two situations: either during an exacerbation or when in front of symptoms of respiratory sleep disturbances. The patient is referred to sleep laboratory for screening for OSA. Ventilatory management of these patients will depend on the patient's underlying condition and on sleep study results. It includes CPAP or NIPPV but frequently additional O(2) addition is necessary. OHS represents today one of the most frequent indications of NIV worldwide.
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Affiliation(s)
- C Rabec
- Service de pneumologie et réanimation respiratoire, CHU de Dijon, 2, boulevard Maréchal-de-Lattre-de-Tassigny, 21079 Dijon, France.
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Marrone O. Complex sleep apnea and obesity hypoventilation syndrome. Opposite ends of the spectrum of obstructive sleep apnea? Med Hypotheses 2009; 73:488-92. [PMID: 19596168 DOI: 10.1016/j.mehy.2009.03.060] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2009] [Revised: 03/28/2009] [Accepted: 03/31/2009] [Indexed: 12/28/2022]
Abstract
In most cases, the application of continuous positive airway pressure (CPAP) during sleep in patients affected by obstructive sleep apnea (OSA) eliminates upper airway obstruction and makes breathing stable and regular. However, some OSA patients develop periodic breathing and central apneas during CPAP administration, a finding that has been labelled as "complex sleep apnea" (complex SA). Such breathing disorder may occur only acutely after CPAP treatment initiation or sometimes persist with chronic CPAP treatment. We hypothesize that complex SA may be the consequence of mechanisms analogous to those leading to obesity hypoventilation syndrome (OHS), but operating in an opposite direction. Periodic breathing is one of the factors predisposing to OSA and is an essential factor for the recurrence of central apneas in normo or hypocapnic patients. A high ventilatory responsiveness to chemical stimuli enhances breathing periodicity. In subjects with periodic central apneas chemoresponsiveness is high, while in subjects with OSA it spans throughout a wide range, and is correlated to diurnal blood gas levels. In fact, sleep respiratory disorders may be responsible for either an augmentation in ventilatory responses to chemical stimuli consequent to chronic exposure to intermittent hypoxia, or for a decrease in ventilatory responses when prolonged exposure to hypercapnia is experienced. Among OSA subjects, those with OHS show very depressed hypercapnic responses. After chronic OSA treatment, ventilatory responses to chemical stimuli may either decrease, in previously hyperresponsive subjects, or increase, in previously hyporesponsive subjects. Most patients with OHS decrease daytime PCO(2) levels and increase their ventilatory responses after chronic CPAP treatment. Complex SA could appear in those OSA subjects in whom chronic exposure to nocturnal respiratory disorders leads to the highest responsiveness to chemical stimuli, and could disappear after blunting of ventilatory responses following chronic CPAP treatment. Complex SA may be one extreme of evolutionary spectrum of OSA, the opposite end being represented by OHS.
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Affiliation(s)
- Oreste Marrone
- Consiglio Nazionale delle Ricerche, Istituto di Biomedicina e Immunologia Molecolare, Via Ugo La Malfa, 153, 90146 Palermo, Italy.
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Abstract
This review discusses the pathophysiological aspects of sleep-disordered breathing, with focus on upper airway mechanics in obstructive and central sleep apnoea, Cheyne-Stokes respiration and obesity hypoventilation syndrome. These disorders constitute the end points of a spectrum with distinct yet interrelated mechanisms that lead to substantial pathology, i.e. increased upper airway collapsibility, control of breathing instability, increased work of breathing, disturbed ventilatory system mechanics and neurohormonal changes. Concepts are changing. Although sleep apnoea is considered more and more to be an increased loop gain disorder, the central type of apnoea is now considered as an obstructive event, because it causes pharyngeal narrowing, associated with prolonged expiration. Although a unifying concept for the pathogenesis is lacking, it seems that these patients are in a vicious circle. Knowledge of common patterns of sleep-disordered breathing may help to identify these patients and guide therapy.
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Affiliation(s)
- Johan A Verbraecken
- Department of Pulmonary Medicine, Antwerp University Hospital and University of Antwerp, BE-2650 Edegem, Belgium.
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Affiliation(s)
- Hiren Muzumdar
- Division of Respiratory and Sleep Medicine, The Children's Hospital at Montefiore, Albert Einstein College of Medicine, 3415 Bainbridge Avenue, Bronx, NY 10467 2490, USA
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Pandit JJ. Structure-function relationships: a breath of fresh air--or just more hot air--in sleep apnoea research? Respiration 2008; 76:16-8. [PMID: 18583924 DOI: 10.1159/000127578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Assessment and management of patients with obesity hypoventilation syndrome. Ann Am Thorac Soc 2008; 5:218-25. [PMID: 18250215 DOI: 10.1513/pats.200708-122mg] [Citation(s) in RCA: 176] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Obesity hypoventilation syndrome (OHS) is characterized by obesity, daytime hypercapnia, and sleep-disordered breathing in the absence of significant lung or respiratory muscle disease. Compared with eucapnic morbidly obese patients and eucapnic patients with sleep-disordered breathing, patients with OHS have increased health care expenses and are at higher risk of developing serious cardiovascular disease leading to early mortality. Despite the significant morbidity and mortality associated with this syndrome, diagnosis and institution of effective treatment occur late in the course of the syndrome. Given that the prevalence of extreme obesity has increased considerably, it is likely that clinicians will encounter patients with OHS in their clinical practice. Therefore maintaining a high index of suspicion can lead to early recognition and treatment reducing the high burden of morbidity and mortality and related health care expenditure associated with undiagnosed and untreated OHS. In this review we define the clinical characteristics of the syndrome and review the pathophysiology, morbidity, and mortality associated with it. Last, we discuss currently available treatment modalities.
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Kawata N, Tatsumi K, Terada J, Tada Y, Tanabe N, Takiguchi Y, Kuriyama T. Daytime Hypercapnia in Obstructive Sleep Apnea Syndrome. Chest 2007; 132:1832-8. [DOI: 10.1378/chest.07-0673] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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Mokhlesi B, Tulaimat A, Faibussowitsch I, Wang Y, Evans AT. Obesity hypoventilation syndrome: prevalence and predictors in patients with obstructive sleep apnea. Sleep Breath 2007; 11:117-24. [PMID: 17187265 DOI: 10.1007/s11325-006-0092-8] [Citation(s) in RCA: 157] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Patients with obesity hypoventilation syndrome (OHS) have a lower quality of life, more healthcare expenses, a greater risk of pulmonary hypertension, and a higher mortality compared to eucapnic patients with obstructive sleep apnea (OSA). Despite significant morbidity and mortality associated with OHS, it is often unrecognized and treatment is frequently delayed. The objective of this observational study was to determine the prevalence of OHS in patients with OSA seen at the sleep disorders clinic of a large public urban hospital serving predominantly minority population and to identify clinical--not mechanistic--predictors that should prompt clinicians to measure arterial blood gases. In the first stage, we randomly selected 180 patients referred to our sleep disorders clinic between 2000 and 2004 for suspicion of OSA. From this retrospective random sample we calculated the prevalence of OHS in patients with OSA and identified independent clinical predictors using logistic regression. In the second stage, we prospectively validated these predictors in a sample of 410 consecutive patients referred to the sleep disorders clinic for suspicion of OSA between 2005 and 2006. The prevalence of OHS in patients with OSA was 30% in the retrospective random sample and 20% in the prospective sample. Three variables independently predicted OHS in both samples: serum bicarbonate level (p < 0.001), apnea-hypopnea index (p = 0.006), and lowest oxygen saturation during sleep (p < 0.001). Due to the serious morbidity associated with OHS, we selected a highly sensitive threshold of serum bicarbonate level. A threshold of 27 mEq/l had a sensitivity of 92% and a specificity of 50%. Only 3% of patients with a serum bicarbonate level <27 mEq/l had hypercapnia compared to 50% with a serum bicarbonate > or =27 mEq/l. In conclusion, OHS is common in severe OSA. A normal serum bicarbonate level excludes hypercapnia and an elevated serum bicarbonate level should prompt clinicians to measure arterial blood gases.
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Affiliation(s)
- Babak Mokhlesi
- Sleep Disorders Center, Section of Pulmonary and Critical Care Medicine, The University of Chicago Pritzker School of Medicine, 5841 S. Maryland Ave. L11B, Chicago, IL 60637, USA.
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Robert D, Argaud L. Non-invasive positive ventilation in the treatment of sleep-related breathing disorders. Sleep Med 2007; 8:441-52. [PMID: 17470410 DOI: 10.1016/j.sleep.2007.03.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2007] [Accepted: 03/12/2007] [Indexed: 12/13/2022]
Abstract
This chapter addresses the use of long-term non-invasive positive pressure ventilation (NIPPV) (to the exclusion of continuous positive airway pressure) in the different clinical settings in which it is currently proposed: principally in diseases responsible for hypoventilation characterized by elevated PaCO(2). Nasal masks are predominantly used, followed by nasal pillow and facial masks. Mouthpieces are essentially indicated in case daytime ventilation is needed. Many clinicians currently prefer pressure-preset ventilator in assist mode as the first choice for the majority of the patients with the view of offering better synchronization. Nevertheless, assist-control mode with volume-preset ventilator is also efficient. The settings of the ventilator must insure adequate ventilation assessed by continuous nocturnal records of at least oxygen saturation of haemoglobin-measured by pulse oximetry. The main categories of relevant diseases include different types of neuromuscular disorders, chest-wall deformities and even lung diseases. Depending on the underlying diseases and on individual cases, two schematic situations may be individualized. Either intermittent positive pressure ventilation (IPPV) is continuously mandatory to avoid death in the case of complete or quasi-complete paralysis or is used every day for several hours, typically during sleep, producing enough improvement to allow free time during the daylight in spontaneous breathing while hypoventilation and related symptoms are improved. In case of complete or quasi-complete need of mechanical assistance, a tracheostomy may become an alternative to non-invasive access. In neuromuscular diseases, in kyphosis and in sequela of tuberculosis patients, NIPPV always significantly increases survival. Conversely, no data support a positive effect on survival in chronic obstructive pulmonary disease.
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Affiliation(s)
- Dominique Robert
- University Claude Bernard, Lyon-Nord Medical School, 8, avenue Rockefeller, 69008 Lyon, France.
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Han F, Song W, Li J, Zhang L, Dong X, He Q. Influence of UPPP surgery on tolerance to subsequent continuous positive airway pressure in patients with OSAHS. Sleep Breath 2007; 10:37-42. [PMID: 16432757 DOI: 10.1007/s11325-005-0041-y] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
To investigate the effect of uvlopalatopharyngoplasty (UPPP) on post-surgery continuous positive airway pressure (CPAP) treatment during sleep in patients with obstructive sleep apnea-hypopnea syndrome (OSAHS). Thirty-one OSAHS patients after UPPP surgery were recruited and studied on for more than 12 months after the procedure. Among them, 24 patients were treated with classical UPPP (cUPPP), which removes all of uvula and part of the soft palate. Seven had modified UPPP (mUPPP), keeping part of the uvula. The control group was 31 years in age, body mass index (BMI) and apnea-hypopnea index (AHI) matched, and newly diagnosed OSAHS patients without prior treatment. A manual titration of CPAP was performed during both (NREM) and non-rapid eye movement (NREM) sleep in all 62 patients. Patients were asked to keep a supine position while sleeping during the test. When significant mouth air leakage occurred and/or titration worsened with an increase of CPAP pressure, the pressure level was considered as the highest CPAP (hCPAP) a patient can tolerate in that sleep stage. The CPAP machine used for titration could produce highest pressure at 20 cm H2O. There were 74% (23/31) of UPPP patients who had less than 50% decrease in AHI, and 84% (26/31) of the 31 patients still had AHI>15 (range 16-110) during post-operation polysomnography (PSG) test. Most of them need further CPAP therapy. All of the untreated OSAHS patients could tolerate 17-20 cm H2O of CPAP during sleep. None had severe mouth air leak before an optimal pressure was reached. In contrast, four in the surgery group failed to respond to CPAP treatment during both NREM and REM sleep and one more during REM sleep. All of the seven patients who had a mUPPP could tolerate CPAP. One of the three tested both before and after surgery failed in the CPAP treatment after surgery during REM sleep. UPPP may compromise nasal CPAP therapy in OSAHS, especially in procedures with greater resection of the soft palate.
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Affiliation(s)
- Fang Han
- Department of Pulmonary Medicine, People's Hospital, Beijing University, 11# Xi Zhi Men Nan Da Jie, Xi Chen Qu, Beijing, 100044, People's Republic of China.
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Chouri-Pontarollo N, Borel JC, Tamisier R, Wuyam B, Levy P, Pépin JL. Impaired Objective Daytime Vigilance in Obesity-Hypoventilation Syndrome. Chest 2007; 131:148-55. [PMID: 17218569 DOI: 10.1378/chest.06-1159] [Citation(s) in RCA: 95] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Obesity-hypoventilation syndrome (OHS) is efficiently treated by noninvasive ventilation (NIV). Sleep respiratory disturbances, reduced ventilatory drive, and excessive daytime sleepiness (EDS) are commonly reported, but their relationships remain unclear. OBJECTIVES To characterize sleep breathing disorders encountered in patients with OHS, to compare low and normal CO(2) responders in terms of sleep abnormalities, subjective and objective measures of EDS, and to measure the changes induced by NIV on these parameters. METHODS At baseline and after 5 nights of NIV, 15 consecutive patients (mean [+/- SD] age, 55 +/- 9 years; mean body mass index, 38.7 +/- 6.1 kg/m(2); Paco(2), 47.3 +/- 2.3 mm Hg) prospectively underwent polysomnography, CO(2) ventilatory response testing, Epworth sleepiness scale scoring, and the Oxford Sleep Resistance (OSLER) test, which is an objective vigilance test. RESULTS OHS patients exhibited obstructive sleep apnea syndrome (mean apnea-hypopnea index, 62 +/- 32 events per hour) and rapid eye movement (REM) sleep hypoventilation (mean REM sleep time, 35 +/- 33%). Baseline CO(2) sensitivity was significantly related to the proportion of hypoventilation during REM sleep (r = 0.54; p = 0.037). Six patients showed abnormal sleep latencies during the OSLER test (71% of the low CO(2) responders vs 14% of the normal CO(2) responders). Low CO(2) responders exhibited significantly shorter sleep latencies during the OSLER test (23 +/- 14 vs 37 +/- 8 min, respectively; p = 0.05). Using NIV, diurnal blood gas levels were improved and REM sleep hypoventilation were suppressed. Objective sleepiness was improved in low CO(2) responders (p = 0.04). CONCLUSION In OHS patients, the lower the daytime CO(2) response, the higher the proportion of REM sleep hypoventilation and daytime sleepiness. Short-term therapy with NIV improves all of these parameters.
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Affiliation(s)
- Nathalie Chouri-Pontarollo
- Sleep Laboratory and Exploration fonctionelle cardio-respiratoire, Institut National de la Santé et de la Recherche Médicale ERI 0017, University Hospital, Grenoble, France
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Laaban JP, Chailleux E. Daytime hypercapnia in adult patients with obstructive sleep apnea syndrome in France, before initiating nocturnal nasal continuous positive airway pressure therapy. Chest 2005; 127:710-5. [PMID: 15764748 DOI: 10.1378/chest.127.3.710] [Citation(s) in RCA: 92] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
CONTEXT Daytime hypercapnia in patients with obstructive sleep apnea syndrome (OSAS) has a highly variable prevalence in the published studies, and is usually thought to be the consequence of an associated disease, COPD, or severe obesity. STUDY OBJECTIVES To assess the prevalence of daytime hypercapnia in a very large population of adult patients with OSAS, free of associated COPD, and with a wide range of body mass index (BMI), and to evaluate the relationship between daytime hypercapnia and the severity of obesity and obesity-related impairment in lung function. DESIGN Retrospective analysis of prospectively collected data. METHODS The database of the observatory of a national nonprofit network for home treatment of patients with chronic respiratory insufficiency (Association Nationale pour le Traitement a Domicile de l'Insuffisance Respiratoire Chronique) was used. Collected data at treatment initiation were age, apnea-hypopnea index, BMI, FEV(1), vital capacity (VC), and arterial blood gases. The study included 1,141 adult patients with OSAS treated in France with nocturnal nasal continuous positive airway pressure (CPAP), FEV(1) >/= 80% predicted, FEV(1)/VC >/= 70%, and absence of restrictive respiratory disease other than related to obesity. RESULTS The prevalence of daytime hypercapnia (Paco(2) >/= 45 mm Hg) before initiating CPAP therapy was 11% in the whole study population. The prevalence of daytime hypercapnia was 7.2% (27 of 377 patients) with BMI < 30, 9.8% (58 of 590 patients) with BMI from 30 to 40, and 23.6% (41 of 174 patients) with BMI > 40. Patients with daytime hypercapnia had significantly higher BMI values and significantly lower VC, FEV(1), and Pao(2) values than the normocapnic patients. Stepwise multiple regression showed that Pao(2), BMI, and either VC or FEV(1) were the best predictors of hypercapnia, but these variables explained only 9% of the variance in Paco(2) levels. CONCLUSION Daytime hypercapnia was observed in > 1 of 10 patients with OSAS needing CPAP therapy and free of COPD, and was related to the severity of obesity and obesity-related impairment in lung function. However, other mechanisms than obesity are probably involved in the pathogenesis of daytime hypercapnia in OSAS.
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Affiliation(s)
- Jean-Pierre Laaban
- Department of Pneumology, Hôtel-Dieu, 1 place du Parvis Notre-Dame, 75004 Paris, France.
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