RESUMO
BACKGROUND: The connection between obstructive sleep apnea and secondary erythrocytosis is controversial. We hypothesised that there may be a higher prevalence of erythrocytosis in patients with obesity hypoventilation syndrome (OHS) due to persistent hypoxemia. METHODS: The study was a retrospective, cross-sectional review of patients with OHS derived from an established cohort of "non-invasive ventilation" patients at the Department of Sleep Medicine at the Royal Infirmary Medical Centre, Edinburgh (2004-2017). Relevant clinical data were obtained from patient records. RESULTS: The cohort comprised 74 patients with OHS, 44 men (60%), mean age at diagnosis 54 ± 10 years. The mean haematocrit level for the group overall was 0.44, in men 0.45, and in women 0.41. Of 11 patients with erythrocytosis (15%), 7 were men. Thirteen patients (18%) died during follow-up (2004-2017). There was a statistically significant increase in risk of death in patients with higher and lower haematocrit levels compared to that in patients with OHS who had normal haematocrits. CONCLUSIONS: This is the first study showing increased prevalence of erythrocytosis in OHS patients. There was a "U"-shaped correlation with mortality according to haematocrit levels.
Assuntos
Hematócrito , Síndrome de Hipoventilação por Obesidade/sangue , Síndrome de Hipoventilação por Obesidade/mortalidade , Adulto , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Estudos RetrospectivosRESUMO
BACKGROUND AND OBJECTIVE: Average volume-assured pressure support-automated expiratory positive airway pressure (AVAPS-AE) combines an automated positive expiratory pressure to maintain upper airway patency to an automated pressure support with a targeted tidal volume. The aim of this study was to compare the effects of 2-month AVAPS-AE ventilation versus pressure support (ST) ventilation on objective sleep quality in stable patients with OHS. Secondary outcomes included arterial blood gases, health-related quality of life, daytime sleepiness, subjective sleep quality and compliance to NIV. METHODS: This is a prospective multicentric randomized controlled trial. Consecutive OHS patients included had daytime Pa CO2 > 6 kPa, BMI ≥ 30 kg/m2 , clinical stability for more than 2 weeks and were naive from home NIV. PSG were analysed centrally by two independent experts. Primary endpoint was sleep quality improvement at 2 months. RESULTS: Among 69 trial patients, 60 patients had successful NIV setup. Baseline and follow-up PSG were available for 26 patients randomized in the ST group and 30 in the AVAPS-AE group. At baseline, Pa CO2 was 6.94 ± 0.71 kPa in the ST group and 6.61 ± 0.71 in the AVAPS-AE group (P = 0.032). No significant between-group difference was observed for objective sleep quality indices. Improvement in Pa CO2 was similar between groups with a mean reduction of -0.87 kPa (95% CI: -1.12 to -0.46) in the ST group versus -0.87 kPa (95% CI: -1.14 to -0.50) in the AVAPS-AE group (P = 0.984). Mean NIV use was 6.2 h per night in both groups (P = 0.93). NIV setup duration was shorter in the AVAPS-AE group (P = 0.012). CONCLUSION: AVAPS-AE and ST ventilation for 2 months had similar impact on sleep quality and gas exchange.
Assuntos
Síndrome de Hipoventilação por Obesidade/fisiopatologia , Respiração com Pressão Positiva , Gasometria , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Ventilação não Invasiva , Síndrome de Hipoventilação por Obesidade/sangue , Polissonografia , Estudos Prospectivos , Qualidade de Vida , SonoRESUMO
STUDY OBJECTIVES: Longitudinal studies support the usage of positive airway pressure (PAP) therapy in treating obstructive sleep apnea (OSA) to improve cardiovascular disease. However, the anticipated benefit is not ubiquitous. In this study, we elucidate whether PAP therapy leads to immediate improvements on endothelial function, a subclinical marker of cardiovascular status, by examining the effect of circulating exosomes, isolated from patients before and after PAP therapy, on naive endothelial cells. METHODS: We isolated plasma-derived circulating exosomes from 12 patients with severe OSA and obesity hypoventilation syndrome (OHS) before and after 6 weeks of PAP therapy, and examined their effect on cultured endothelial cells using several in vitro reporter assays. RESULTS: We found that circulating exosomes contributed to the induction and propagation of OSA/OHS-related endothelial dysfunction (ie, increased permeability and disruption of tight junctions along with increased adhesion molecule expression, and reduced endothelial nitric oxide synthase expression), and promoted increased monocyte adherence. Further, when comparing exosomes isolated before and after PAP therapy, the disturbances in endothelial cell function were attenuated with treatment, including an overall cumulative decrease in endothelial permeability in all 12 subjects by 10.8% (P = .035), as well as detection of a subset of 4 differentially expressed exosomal miRNAs, even in the absence of parallel changes in systemic blood pressure or metabolic function. CONCLUSIONS: Circulating exosomes facilitate important intercellular signals that modify endothelial phenotype, and thus emerge as potential fundamental contributors in the context of OSA/OHS-related endothelial dysfunction. Exosomes may not only provide candidate biomarkers, but are also a likely and plausible mechanism toward OSA/OHS-induced cardiovascular disease. CLINICAL TRIAL REGISTRATION: Registry: ClinicalTrials.gov, Title: AVAPS-AE Efficacy Study, URL: https://clinicaltrials.gov/ct2/show/NCT01368614, Identifier: NCT01368614.
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Endotélio Vascular/fisiopatologia , Exossomos/metabolismo , Síndrome de Hipoventilação por Obesidade/terapia , Western Blotting , Células Cultivadas , Pressão Positiva Contínua nas Vias Aéreas , Endotélio Vascular/citologia , Exossomos/genética , Exossomos/fisiologia , Feminino , Imunofluorescência , Humanos , Masculino , Pessoa de Meia-Idade , Síndrome de Hipoventilação por Obesidade/sangue , Síndrome de Hipoventilação por Obesidade/fisiopatologia , Análise de Sequência com Séries de Oligonucleotídeos , Estudo de Prova de Conceito , Reação em Cadeia da Polimerase Via Transcriptase ReversaAssuntos
Síndrome de Hipoventilação por Obesidade/complicações , Apneia Obstrutiva do Sono/complicações , Idoso , Índice de Massa Corporal , Doenças Cardiovasculares/epidemiologia , Comorbidade , Diabetes Mellitus/epidemiologia , Dislipidemias/epidemiologia , Feminino , Seguimentos , Humanos , Masculino , Análise por Pareamento , Pessoa de Meia-Idade , Síndrome de Hipoventilação por Obesidade/sangue , Síndrome de Hipoventilação por Obesidade/epidemiologia , Oxigênio/sangue , Prognóstico , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/mortalidade , Estudos Retrospectivos , Apneia Obstrutiva do Sono/sangue , Apneia Obstrutiva do Sono/epidemiologia , Fumar/epidemiologiaRESUMO
BACKGROUND AND OBJECTIVE: The prevalence of obesity hypoventilation syndrome (OHS) in the unselected obese is unknown. Our objectives were: (i) to determine the prevalence of OHS in ambulatory obese patients not previously referred to a pulmonologist for suspicion of sleep breathing disorders and (ii) to assess whether venous bicarbonate concentration [HCO3-v ] can be used to detect OHS. METHODS: In this prospective multicentric study, we measured [HCO3-v ] in consenting obese patients attending pathology analysis laboratories. Patients with [HCO3-v ] ≥ 27 mmol/L were referred to a pulmonologist for comprehensive sleep and respiratory evaluations. Those with [HCO3-v ] < 27 mmol/L were randomized to either referral to a pulmonologist or ended the study. RESULTS: For the 1004 screened patients, the [HCO3-v ] was ≥27 mmol/L in 24.6% and <27 mmol/L in 45.9%. A total of 29.5% who had previously consulted a pulmonologist were excluded. A population of 241 obese patients underwent sleep and respiratory assessments. The prevalence of OHS in this population was 1.10 (95% CI = 0.51; 2.27). In multivariate analysis, PaCO2 , forced expiratory volume in 1 s (FEV1 ), apnoea-hypopnoea index (AHI), BMI, use of ≥3 anti-hypertensive drugs, anti-diabetics, proton pump inhibitors and/or paracetamol were related to raised [HCO3-v ]. CONCLUSION: The prevalence of OHS in our obese population was lower than previous estimations based on hospitalized patients or clinical cohorts with sleep breathing disorders. Apart from hypercapnia, increased [HCO3-v ] may also reflect multimorbidity and polypharmacy, which should be taken into account when using [HCO3-v ] to screen for OHS.
Assuntos
Síndrome de Hipoventilação por Obesidade/epidemiologia , Obesidade/complicações , Adulto , Bicarbonatos/sangue , Feminino , Volume Expiratório Forçado , Humanos , Masculino , Pessoa de Meia-Idade , Obesidade/sangue , Obesidade/fisiopatologia , Síndrome de Hipoventilação por Obesidade/sangue , Síndrome de Hipoventilação por Obesidade/diagnóstico , Prevalência , Estudos Prospectivos , Testes de Função RespiratóriaRESUMO
BACKGROUND: As obesity increases, the frequency of obstructive sleep apnea and obesity hypoventilation syndrome increases also. However, obesity hypoventilation syndrome frequency is not known, as capnography and arterial blood gas analysis are not routinely performed in sleep laboratories. AIMS: To investigate the frequency and predictors of obesity hypoventilation syndrome in obese subjects. STUDY DESIGN: Retrospective clinical study. METHODS: Obese subjects who had arterial blood gas analysis admitted to the sleep laboratory and polysomnography were retrospectively analyzed. Subjects with restrictive (except obesity) and obstructive pulmonary pathologies were excluded. Demographics, Epworth-Sleepiness-Scale scores, polysomnographic data, arterial blood gas analysis, and spirometric measurements were recorded. RESULTS: Of the 419 subjects, 45.1% had obesity hypoventilation syndrome. Apnea hypopnea index (p<0.001), oxygen desaturation index (p<0.001) and sleep time with SpO2<90% (p<0.001) were statistically higher in subjects with obesity hypoventilation syndrome compared to subjects with eucapnic obstructive sleep apnea. The nocturnal mean SpO2 (p<0.001) and lowest SpO2 (p<0.001) were also statistically lower in subjects with obesity hypoventilation syndrome. Logistic regression analysis showed that the lowest SpO2, oxygen desaturation index, apnea hypopnea index and sleep time with SpO2 <90% were related factors for obesity hypoventilation syndrome. CONCLUSION: Obesity hypoventilation syndrome should be considered when oxygen desaturation index, apnea hypopnea index and sleep time with SpO2 <90% are high.
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Gasometria/estatística & dados numéricos , Síndrome de Hipoventilação por Obesidade/complicações , Síndrome de Hipoventilação por Obesidade/diagnóstico , Apneia Obstrutiva do Sono/etiologia , Adulto , Índice de Massa Corporal , Feminino , Humanos , Modelos Logísticos , Masculino , Pessoa de Meia-Idade , Síndrome de Hipoventilação por Obesidade/sangue , Estudos Retrospectivos , Estatísticas não ParamétricasRESUMO
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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Pressão Positiva Contínua nas Vias Aéreas , Ventilação não Invasiva , Síndrome de Hipoventilação por Obesidade/terapia , Cooperação do Paciente , Qualidade de Vida , Idoso , Idoso de 80 Anos ou mais , Feminino , França , Humanos , Masculino , Pessoa de Meia-Idade , Síndrome de Hipoventilação por Obesidade/sangue , Oximetria , Projetos Piloto , Polissonografia , Estudos Prospectivos , Testes de Função Respiratória , Falha de TratamentoRESUMO
PURPOSE OF REVIEW: The prevalence of sleep disordered breathing (SDB) is increasing proportional to the prevalence of obesity. Although anesthesiologists are familiar with obstructive sleep apnea (OSA) - the most common SDB, anesthesiologists may not be aware of other SDB such as obesity hypoventilation syndrome (OHS) and overlap syndrome (combination of OSA and chronic obstructive pulmonary disease). The present review provides an update of information regarding the perioperative management of OHS and overlap syndrome. RECENT FINDINGS: OHS and overlap syndrome are associated with significant comorbid conditions and more perioperative morbidity than OSA alone. Similar to OSA, most of the OHS patients are undiagnosed. An increase in serum bicarbonate level is a surrogate marker of hypercapnia. Because 90% of OHS patients have OSA, preoperative screening for OSA combined with estimation of serum bicarbonate level may detect the majority of the patients with OHS. In patients with OSA, OHS, and overlap syndrome, improvement in the perioperative outcome has been shown by initiating positive airway pressure therapy. SUMMARY: Identification and preoperative optimization of these high-risk patients are most important. A protocol-based risk mitigation is necessary for improving the intraoperative and postoperative outcome of these patients. As a perioperative physician, anesthesiologists have a key role in the management of patients with SDB.
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Procedimentos Cirúrgicos Eletivos/efeitos adversos , Síndrome de Hipoventilação por Obesidade/complicações , Assistência Perioperatória/métodos , Complicações Pós-Operatórias/prevenção & controle , Doença Pulmonar Obstrutiva Crônica/complicações , Anestesia/efeitos adversos , Anestesia/métodos , Anestesia/normas , Bicarbonatos/sangue , Humanos , Síndrome de Hipoventilação por Obesidade/sangue , Síndrome de Hipoventilação por Obesidade/diagnóstico , Síndrome de Hipoventilação por Obesidade/epidemiologia , Assistência Perioperatória/efeitos adversos , Assistência Perioperatória/normas , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Guias de Prática Clínica como Assunto , Prevalência , Doença Pulmonar Obstrutiva Crônica/sangue , Doença Pulmonar Obstrutiva Crônica/diagnóstico , Doença Pulmonar Obstrutiva Crônica/epidemiologia , Medição de RiscoRESUMO
BACKGROUND: Obesity hypoventilation syndrome (OHS) is associated with a high burden of cardiovascular morbidity (CVM) and mortality. The majority of patients with OHS have concomitant OSA, but there is a paucity of data on the association between CVM and OSA severity in patients with OHS. The objective of our study was to assess the association between CVM and OSA severity in a large cohort of patients with OHS. METHODS: In a cross-sectional analysis, we examined the association between OSA severity based on tertiles of oxygen desaturation index (ODI) and CVM in 302 patients with OHS. Logistic regression models were constructed to quantify the independent association between OSA severity and prevalent CVM after adjusting for various important confounders. RESULTS: The prevalence of CVM decreased significantly with increasing severity of OSA based on ODI as a continuous variable or ODI tertiles. This inverse relationship between OSA severity and prevalence of CVM was seen in the highest ODI tertile and it persisted despite adjustment for multiple confounders. Chronic heart failure had the strongest negative association with the highest ODI tertile. No significant CVM risk change was observed between the first and second ODI tertiles. Patients in the highest ODI tertile were younger, predominantly male, more obese, more hypersomnolent, had worse nocturnal and daytime gas exchange, lower prevalence of hypertension, better exercise tolerance, and fewer days hospitalized than patients in the lowest ODI tertile. CONCLUSIONS: In patients with OHS, the highest OSA severity phenotype was associated with reduced risk of CVM. This finding should guide the design of future clinical trials assessing the impact of interventions aimed at decreasing cardiovascular morbidity and mortality in patients with OHS. TRIAL REGISTRY: Clinicaltrial.gov; No.: NCT01405976; URL: www.clinicaltrials.gov.
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Doenças Cardiovasculares , Síndrome de Hipoventilação por Obesidade , Idoso , Gasometria/métodos , Doenças Cardiovasculares/etiologia , Doenças Cardiovasculares/mortalidade , Estudos Transversais , Feminino , Humanos , Hipóxia/diagnóstico , Hipóxia/etiologia , Masculino , Pessoa de Meia-Idade , Síndrome de Hipoventilação por Obesidade/sangue , Síndrome de Hipoventilação por Obesidade/complicações , Síndrome de Hipoventilação por Obesidade/diagnóstico , Síndrome de Hipoventilação por Obesidade/epidemiologia , Polissonografia/métodos , Prevalência , Fatores de Proteção , Índice de Gravidade de Doença , EspanhaRESUMO
BACKGROUND: Measurement of PCO2 is vital in determining effective alveolar ventilation. However, obtaining capillary PCO2 by a skin prick of the earlobe is painful, and nocturnal measurements disturb sleep. End-expiratory measurement of PCO2 is also well established, but there is a low precision in predicting arterial or capillary CO2. The purpose of the study was to evaluate nocturnal measurement of noninvasive, transcutaneous PCO2 (PtcCO2 ) measurement in hypercapnic subjects. METHODS: In this prospective study, 31 subjects with chronic hypercapnic failure--in a stable phase of the underlying disease--and a control group of 12 healthy volunteers were included. Transcutaneous measurements were taken by the Tosca sensor (Radiometer, Copenhagen, Denmark) over a period of at least 6 h during the night. A capillary blood gas was measured at midnight and 4:00 am. RESULTS: The mean nocturnal capillary PCO2 (PcapCO2 ) of subjects was 50.6 ± 10.2 mm Hg. In the 31 subjects with known hypercapnic respiratory failure, the correlation between PtcCO2 and PcapCO2 at midnight was 0.86 and at 4:00 am r = 0.80. The bias of the hypercapnic subjects was d = + 4.5 with a limit(s) of agreement of 2 SD = 13.0. The process of blood sampling caused no significant change in PtcCO2 . CONCLUSIONS: Our study evaluated transcutaneous capnography as a continuous nocturnal measurement in hypercapnic subjects. We found a good agreement between the methods. Because CO2 is not constant in patients with respiratory failure, but instead fluctuates, we would recommend the continuous transcutaneous measurement of PCO2 as our method of choice in the diagnosis of nocturnal hypercapnia.
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Monitorização Transcutânea dos Gases Sanguíneos , Hipercapnia/sangue , Hipercapnia/diagnóstico , Adulto , Idoso , Idoso de 80 Anos ou mais , Gasometria , Capilares , Dióxido de Carbono , Doença Crônica , Pavilhão Auricular/irrigação sanguínea , Humanos , Hipercapnia/etiologia , Pessoa de Meia-Idade , Síndrome de Hipoventilação por Obesidade/sangue , Síndrome de Hipoventilação por Obesidade/complicações , Pressão Parcial , Estudos Prospectivos , Doença Pulmonar Obstrutiva Crônica/sangue , Doença Pulmonar Obstrutiva Crônica/complicações , Escoliose/sangue , Escoliose/complicações , Sono/fisiologia , Fatores de Tempo , Adulto JovemRESUMO
Noninvasive ventilation is recommended to correct the nocturnal hypoventilation and relieve the symptoms of patients with the obesity-hypoventilation syndrome (OHS). The benefits of fixed pressure ventilation (S/T technology) are recognized but limited on account of the variability of nocturnal ventilatory requirements. The new technique AVAPS-AE (automatic EPAP) allows adjustment of the pressure according to the volume currently targeted. Its efficacy has not yet been evaluated. Our objectives are to evaluate firstly, whether AVAPS-AE optimizes the benefits of S/T technology on sleep architecture and quality, secondly, whether these benefits are associated with an improvement in gas exchange, symptoms, exercise tolerance, level of physical activity and quality of life of patients with OHS. In this multicenter trial, 60 newly diagnosed patients with OHS will be randomized to the control (S/T) and trial (AVAPS-AE) groups. A standardized titration procedure will be followed for the calibration of the ventilators. Functional evaluations (polysomnography, blood gases, impedance measurements and walking tests), questionnaires (physical activity, quality of life, quality of sleep and daytime somnolence) visual scales (fatigue, headaches) and a recording of activity will be undertaken after two months of ventilation.
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Ventilação não Invasiva/métodos , Síndrome de Hipoventilação por Obesidade/terapia , Respiração com Pressão Positiva/métodos , Resistência das Vias Respiratórias , Automação , Gasometria , Distúrbios do Sono por Sonolência Excessiva/etiologia , Desenho de Equipamento , Tolerância ao Exercício , Expiração , Fadiga/etiologia , Cefaleia/etiologia , Humanos , Inalação , Síndrome de Hipoventilação por Obesidade/sangue , Síndrome de Hipoventilação por Obesidade/complicações , Síndrome de Hipoventilação por Obesidade/fisiopatologia , Síndrome de Hipoventilação por Obesidade/psicologia , Seleção de Pacientes , Polissonografia , Qualidade de Vida , Projetos de Pesquisa , Inquéritos e QuestionáriosRESUMO
BACKGROUND: Arterial blood gas (ABG) analysis is not a routine test in sleep laboratories due to its invasive nature. Therefore, the diagnosis of obesity hypoventilation syndrome (OHS) is underestimated. We aimed to evaluate the differences in subjects with OHS and pure obstructive sleep apnea (OSA) and to determine clinical predictors of OHS in obese subjects. METHODS: Demographics, body mass index (BMI), Epworth Sleepiness Scale score, polysomnographic data, ABG, spirometric measurements, and serum bicarbonate levels were recorded. RESULTS: Of 152 obese subjects with OSA (79 females/73 males, mean age of 50.3 ± 10.6 y, BMI of 40.1 ± 5.6 kg/m(2), 51.9% with severe OSA), 42.1% (n = 64) had OHS. Subjects with OHS had higher BMI (P = .02), neck circumference (P < .001), waist circumference (P < .001), waist/hip ratio (P = .02), Epworth Sleepiness Scale scores (P = .036), ABG and serum bicarbonate levels (P < .001), apnea-hypopnea index (P = .01), oxygen desaturation index (P < .001), and total sleep time with S(pO2) < 90% (P < .001) compared with subjects with pure OSA (n = 88). They also had lower daytime PaO2 (P < .001), sleep efficiency (P = .032), mean S(pO2) (P < .001), and nadir S(pO2) (P < .001). Serum bicarbonate levels and nadir S(pO2) were the only independent predictive factors for OHS. A serum bicarbonate level of ≥ 27 mmol/L as the cutoff gives a satisfactory discrimination for the diagnosis of OHS (sensitivity of 76.6%, specificity of 74.6%, positive predictive value of 54.5%, negative predictive value of 88.9%). A nadir S(pO2) of < 80% as the cutoff gives a satisfactory discrimination for the diagnosis of OHS (sensitivity of 82.8%, specificity of 54.5%, positive predictive value of 56.9%, negative predictive value of 81.4%). When we used a serum bicarbonate level of ≥ 27 mmol/L and/or a nadir S(pO2) of < 80% as a screening measure, only 3 of 64 subjects with OHS were missed. CONCLUSIONS: Serum bicarbonate level and nadir saturation were independent predictive factors for the diagnosis of OHS.
Assuntos
Síndrome de Hipoventilação por Obesidade/etiologia , Obesidade/complicações , Apneia Obstrutiva do Sono/etiologia , Idoso , Bicarbonatos/sangue , Gasometria , Índice de Massa Corporal , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Obesidade/sangue , Síndrome de Hipoventilação por Obesidade/sangue , Polissonografia , Valor Preditivo dos Testes , Fatores de Risco , Sono , Apneia Obstrutiva do Sono/sangue , Relação Cintura-QuadrilRESUMO
INTRODUCTION: Obesity is associated with 2 closely related respiratory diseases: obesity hypoventilation syndrome (OHS) and obstructive sleep apnea-hypopnea syndrome (OSAHS). It has been shown that noninvasive ventilation during sleep produces clinical and functional improvement in these patients. The long-term survival rate with this treatment, and the difference in clinical progress in OHS patients with and without OSAHS are analyzed. METHODOLOGY: Longitudinal, observational study with a cohort of patients diagnosed with OHS, included in a home ventilation program over a period of 12 years, divided into 2 groups: pure OHS and OSAHS-associated OHS. Bi-level positive airway pressure ventilation was administered. During the follow-up period, symptoms, exacerbations and hospitalizations, blood gas tests and pulmonary function tests, and survival rates were monitored and compared. RESULTS: Eighty-three patients were eligible for analysis, 60 women (72.3%) and 23 men (27.7%), with a mean survival time of 8.47 years. Fifty patients (60.2%) were included in the group without OSAHS (OHS) and 33 (39.8%) in the OSAHS-associated OHS group (OHS-OSAHS). PaCO2 in the OHS group was significantly higher than in the OHS-OSAHS group (P<.01). OHS patients also had a higher hospitalization rate (P<.05). There was a significant improvement in both groups in FEV1 and FVC, and no differences between groups in PaCO2 and PaO2 values. There were no differences in mortality between the 2 groups, but low FVC values were predictive of mortality. CONCLUSIONS: The use of mechanical ventilation in patients with OHS, with or without OSAHS, is an effective treatment for the correction of blood gases and functional alterations and can achieve prolonged survival rates.
Assuntos
Pressão Positiva Contínua nas Vias Aéreas , Síndrome de Hipoventilação por Obesidade/terapia , Idoso , Dióxido de Carbono/sangue , Feminino , Volume Expiratório Forçado , Serviços de Assistência Domiciliar , Humanos , Hipercapnia/etiologia , Hipercapnia/terapia , Masculino , Pessoa de Meia-Idade , Síndrome de Hipoventilação por Obesidade/sangue , Síndrome de Hipoventilação por Obesidade/mortalidade , Síndrome de Hipoventilação por Obesidade/fisiopatologia , Oxigênio/sangue , Pressão Parcial , Cooperação do Paciente , Polissonografia , Prognóstico , Estudos Prospectivos , Capacidade VitalRESUMO
BACKGROUND AND OBJECTIVE: Obesity hypoventilation syndrome (OHS) prevalence was previously estimated at 9% in patients with obstructive sleep apnoea (OSA) in Japan. However, the definition of OSA in that study was based on an apnoea-hypopnoea index (AHI) of ≥ 20/h rather than ≥ 5/h. Therefore, the prevalence of OHS in OSA was not measured in the same way as for Western countries. Our study objectives were to investigate the characteristics of Japanese patients with OHS. METHODS: Nine hundred eighty-one consecutive patients investigated for suspected OSA were enrolled. At least 90% of them were from urban areas, including 162 with obese OSA (body mass index (BMI) ≥ 30 kg/m(2) and AHI ≥ 5/h). RESULTS: The prevalence of OHS (BMI 36.7 ± 4.9 kg/m(2) ) in OSA and that in obese OSA were 2.3% and 12.3%, respectively. Multiple regression analysis revealed that independent of age and BMI, arterial oxygen pressure (contribution rate (R(2) ) = 7.7%), 4% oxygen desaturation index (R(2) = 8.9%), carbon monoxide diffusing capacity/alveolar volume (R(2) = 8.3%), haemoglobin concentration (R(2) = 4.9%) and waist circumference (R(2) = 4.9%) were independently associated with arterial carbon dioxide pressure. After 12.3 ± 4.6 months of CPAP treatment, more than 60% of OHS patients no longer had hypercapnia. CONCLUSIONS: The prevalence of OHS in OSA in Japan was 2.3%. The mean BMI of patients with OHS in Japan was lower than that in Western countries (36.7 kg/m(2) vs 44.0 kg/m(2) ).
Assuntos
Dióxido de Carbono/sangue , Síndrome de Hipoventilação por Obesidade , Obesidade , Adulto , Idoso , Gasometria , Monitorização Transcutânea dos Gases Sanguíneos/métodos , Índice de Massa Corporal , Pressão Positiva Contínua nas Vias Aéreas/métodos , Feminino , Humanos , Hipercapnia/fisiopatologia , Japão/epidemiologia , Masculino , Pessoa de Meia-Idade , Obesidade/complicações , Obesidade/diagnóstico , Obesidade/epidemiologia , Síndrome de Hipoventilação por Obesidade/sangue , Síndrome de Hipoventilação por Obesidade/diagnóstico , Síndrome de Hipoventilação por Obesidade/epidemiologia , Síndrome de Hipoventilação por Obesidade/fisiopatologia , Polissonografia/métodos , PrevalênciaRESUMO
BACKGROUND AND OBJECTIVE: Reduced atmospheric pressure during air travel can cause significant hypoxaemia in some patients with respiratory disease. Our aims were to investigate the degree of hypoxaemia in patients with obesity hypoventilation syndrome (OHS) during hypoxic challenge test (HCT), and to identify any predictors of a positive HCT. METHODS: Thirteen patients underwent assessment, including HCT, lung function and incremental shuttle walk test. All had OHS well controlled with long-term nocturnal non-invasive ventilation (NIV). Patients with chronic obstructive pulmonary disease were excluded. A positive HCT was defined according to the British Thoracic Society (BTS) recommendation as arterial oxygen tension (PaO2) <6.6 kPa and/or oxygen saturation <85%. RESULTS: Mean age was 57 (± 11) years. Mean body mass index was 51.7 (± 12) kg/m(2) . Mean baseline PaO2 and arterial carbon dioxide tension (PaCO2) were 10.2 (9.5-11.3) kPa and 5.2 (3.7-6.8) kPa, respectively. Seven patients (54%) had a positive HCT. The correlation between baseline PaO2 and PaO2 at the end of the HCT was not statistically significant (r = 0.433, P = 0.184). A negative correlation was observed between baseline PaCO2 and PaO2 at the end of the HCT (r = -0.793, P = 0.004). A positive correlation was observed between the distance walked and the PaO2 at the end of the HCT (r = 0.608, P = 0.047). CONCLUSIONS: OHS is a risk factor for severe hypoxaemia during air travel even if the ventilatory failure is well controlled. An HCT before air travel is advisable in all OHS patients. Those with positive HCT may use NIV or have oxygen on-board as per BTS recommendation.
Assuntos
Viagem Aérea , Hipóxia , Ventilação não Invasiva/métodos , Síndrome de Hipoventilação por Obesidade , Oxigenoterapia/métodos , Insuficiência Respiratória , Idoso , Gasometria , Índice de Massa Corporal , Testes Respiratórios/métodos , Feminino , Humanos , Hipóxia/etiologia , Hipóxia/prevenção & controle , Masculino , Pessoa de Meia-Idade , Síndrome de Hipoventilação por Obesidade/sangue , Síndrome de Hipoventilação por Obesidade/complicações , Síndrome de Hipoventilação por Obesidade/diagnóstico , Síndrome de Hipoventilação por Obesidade/fisiopatologia , Respiração , Insuficiência Respiratória/etiologia , Insuficiência Respiratória/prevenção & controleRESUMO
INTRODUCTION: Obesity hypoventilation syndrome (OHS) can be overlooked unless clinicians have a high index of suspicion. The present case-control study aimed to compare characteristics of patients with OHS and obese obstructive sleep apnea syndrome (OSAS), and to identify determinants of hypercapnia in OSAS patients. METHODS: Demographic and anthropometric features, pulmonary function tests, blood gas analysis and sleep parameters of 59 OHS patients were compared to 295 body mass index-matched OSAS patients. RESULTS: The rate of hypertension (67.8% vs 53.2%, respectively, P=0.027) was higher in OHS than OSAS group. In OHS patients, FVC (%) (P<0.0001), FEV1 (%) (P=0.001) and PaO2 (P<0.0001) were lower, whereas PaCO2 and HCO3 levels were increased (P<0.0001). Daytime sleepiness was more frequent (89.8% vs 68.5%, respectively, P=0.002), and Epworth sleepiness scores were higher (14.0 vs 11.9, respectively, P=0.021) in OHS than OSAS patients. In polysomnography, lowest and mean SpO2 were decreased, and sleep time with SpO2 <90% was increased in patients with OHS (P<0.0001). Multivariate analysis showed that hypercapnia was associated independently with HCO3 (P<0.0001) and daytime SaO2 (P=0.003). Besides, HCO3 level ≥ 27 mEq/L had a sensitivity of 88.1% and specificity of 73.1%, and SaO2 ≤ 95% had a sensitivity of 64.4% and specificity of 73.9% for identifying OHS. CONCLUSION: It was shown that OHS patients have increased rate of hypertension, daytime sleepiness and HCO3 , and decreased lung functions and PaO2 levels than OSAS patients. The present results support that elevated bicarbonate levels and decreased oxygen saturations in obese OSAS patients should prompt clinicians to predict OHS.
Assuntos
Hipercapnia/etiologia , Síndrome de Hipoventilação por Obesidade/sangue , Síndromes da Apneia do Sono/sangue , Gasometria , Índice de Massa Corporal , Dióxido de Carbono/sangue , Feminino , Humanos , Hipercapnia/fisiopatologia , Masculino , Pessoa de Meia-Idade , Síndrome de Hipoventilação por Obesidade/complicações , Síndrome de Hipoventilação por Obesidade/fisiopatologia , Oxigênio/sangue , Polissonografia , Testes de Função Respiratória , Estudos Retrospectivos , Síndromes da Apneia do Sono/complicações , Síndromes da Apneia do Sono/fisiopatologiaRESUMO
This prospective study investigated the validity of arterialised-venous blood gases (AVBG) for estimating arterial carbon dioxide P CO2, pH and bicarbonate (HCO3(-)) in people with obesity hypoventilation syndrome (OHS). AVBGs were obtained from an upper limb vein, after heating the skin at 42-46°C. Arterial blood gas (ABG) and AVBG samples were taken simultaneously and compared using Bland Altman analysis. Between-group differences were assessed with independent t-tests or Mann-Whitney U tests. Forty-two viable paired samples were analysed, including 27 paired samples from 15 OHS participants, and 15 paired samples from 16 controls. AVBG-ABG agreement was not different between groups, or between dorsal hand, forearm and antecubital AVBG sampling sites, and was clinically acceptable for P Co2: mean difference (MD) 0.4 mmHg (0.9%), limits of agreement (LOA) -2.7-3.6 mmHg (± 6.6%); pH: MD -0.008 (-0.1%), LOA -0.023-0.008 (± 0.2%); and HCO3(-): MD -0.3 mmol L(-1) (-1.0%), LOA -1.8-1.2 mmol L(-1) (± 5.3%). AVBG provides valid measures of [Formula: see text] , pH, and HCO3(-) in OHS.
Assuntos
Bicarbonatos/sangue , Dióxido de Carbono/sangue , Síndrome de Hipoventilação por Obesidade/sangue , Adulto , Artérias , Gasometria , Feminino , Humanos , Concentração de Íons de Hidrogênio , Masculino , Pessoa de Meia-Idade , Reprodutibilidade dos Testes , Estatísticas não Paramétricas , VeiasRESUMO
INTRODUCTION: Automatic titration modes of non-invasive ventilation, including average volume assured pressure support (AVAPS), are hybrid technologies that target a set volume by automated adjustment of pressure support (PS). These automated modes could offer potential advantages over fixed level PS, in particular, in patients who are super obese. METHODS: Consecutive patients with obesity hypoventilation syndrome were enrolled in a two-centre prospective single-blind randomised controlled trial of AVAPS versus fixed-level PS using a strict protocolised setup. MEASUREMENTS: The primary outcome was change in daytime arterial PCO(2) (PaCO(2)) at 3 months. Body composition, physical activity (7-day actigraphy) and health-related quality of life (severe respiratory insufficiency questionnaire, SRI) were secondary outcome measures. RESULTS: 50 patients (body mass index 50±7 kg/m(2); 55±11 years; 53% men) were enrolled with a mean PaCO(2) of 6.9±0.8 kPa and SRI of 53±17. 46 patients (23 AVAPS and 23 PS) completed the trial. At 3 months, improvements in PaCO(2) were observed in both groups (AVAPS 0.6 kPa, 95% CI 0.2 to 1.1, p<0.01 vs PS 0.6 kPa, 95% CI 0.1 to 1.1, p=0.02) but no between-group difference (-0.1 kPa, 95% CI -0.7 to 0.6, p=0.87). SRI also improved in both groups (AVAPS 11, 95% CI 6 to 17, p<0.001 vs PS 7, 95% CI 1 to 12, p=0.02; between groups 5, 95% CI -3 to 12, p=0.21). Secondary analysis of both groups combined showed improvements in daytime physical activity that correlated with reduction in fat mass (r=0.48; p=0.01). CONCLUSION: The study demonstrated no differences between automated AVAPS mode and fixed-level PS mode using a strict protocolised setup in patients who were super obese. The data suggest that the management of sleep-disordered breathing may enhance daytime activity and promote weight loss in super-obese patients.
Assuntos
Síndrome de Hipoventilação por Obesidade/terapia , Respiração com Pressão Positiva/métodos , Adulto , Idoso , Antropometria/métodos , Dióxido de Carbono/sangue , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Atividade Motora/fisiologia , Síndrome de Hipoventilação por Obesidade/sangue , Síndrome de Hipoventilação por Obesidade/fisiopatologia , Oxigênio/sangue , Pressão Parcial , Troca Gasosa Pulmonar/fisiologia , Qualidade de Vida , Método Simples-Cego , Resultado do Tratamento , Redução de Peso/fisiologiaRESUMO
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.