Obesity Hypoventilation Syndrome “OHS” Abdul Alraiyes MD.
©2009 Alraiyes
Objectives
To discuss the obesity hypoventilation and hypercapnia
Hypercapnia and periodic breathing
Apnea / inter-apnea interval ratio
PHOX2B and hypoventilation
Manifestation and approach to diagnosis and management of OHS
©2009 Alraiyes
Consult
63 Y/O male with multiple medical problems admited with CHF exacerbation and SOB
the patient started on CPAP 7 cmH2O during this hospital admission and his sleep and day time sleepiness improved.
©2009 Alraiyes
Sleep History
the patient is a third shift worker for 10 years before he retired 9 years ago and according to him he still having late phase of sleep every night, Bed time: 1:30 am Sleep latency: 5 min Wake up at night: at 4 am for a bathroom use wake up time in am: 9:00am Naps: once a day at 5:00 pm for 1 hour ESS: 16/24 Loud snoring witnessed sleep apneas Got worse over the 8 years with weight gain of 80 pounds. History of car accident 2 years secondary to sleepiness while driving
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PMHx
A.fib CAD CHF HTN DM COPD chronically on 3L oxygen; no PFTs in system OSA
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Medications
ASA Carvedilol Lasix Glipizide NPH Lisinopril Clariitn Omeprazole Simvastatin Coumadin
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Physical Exam V/S T:96.6 F (35.9 C) P: 70 R: 20 B/P: 101/57* Pain: 0 - No pain BMI: 43.6
Morbid obese the patient is a mouth breather HEENT: retrognathia, with MAL III, very busy oropharynx anatomy, enlarged uvula, tonsils #2 no nasal septal deviation or enlarged turbinates. neck 20.5 inches Chest: good air entry bil basal crackles CVS: S1+S2+SEM Abd: obese soft and lax no paradox abdominal breathing and scrotal edema Ext: 2+ pitting edema with. ©2009 Alraiyes
Labs ABG
5.9
13.3 \____/ / 42 \
138
98
143
PH: 7.35 PaCO2: 64.3 PaO2: 87 HCO3: 37
47
___|___|____/ \ 4.8 | 38 | 1.4
110
HCO3 Jun 2003
Aug 2004
Jan 2005
Mar 2005
Jul 2006
Dec 2006
Apr 2008
Mar 2009
Jul 2009
Sep 2009
24
23
25
26
30
28
30
33
32
37
©2009 Alraiyes
2D-Echo
7/09-preserved EF, moderate to severe LVH, LA and RA mod dilated, trace MR, mild TR, no AV stenosis; RV pressures are normal
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Summary
63 Y/O Male with PMHx of DM, HTN, CHF, A-fib, COPD. Admited 2nd to CHF exacerbation and fluid over load treated with diuretics and assessed by Pulmonary team started on CPAP 7 cm H2O Pt symptoms and sleep quality improved.
©2009 Alraiyes
OHS
©2009 Alraiyes
OHS Obesity hypoventilation syndrome (OHS) is characterized by obesity, daytime hypercapnia, and sleep-disordered breathing in the absence of significant lung or respiratory muscle disease.
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©2009 Alraiyes
OHS exclusion of: •severe obstructive or restrictive pulmonary disease •Significant kyphoscoliosis •severe hypothyroidism •neuromuscular diseases.
Babak Mokhlesi, Meir H. Kryger and Ronald R. Grunstein Assessment and Management of Patients with Obesity Hypoventilation Syndrome The Proceedings of the American Thoracic Society 5:218-225 (2008)
©2009 Alraiyes
OHS Epidemiology
Babak Mokhlesi, Meir H. Kryger and Ronald R. Grunstein Assessment and Management of Patients with Obesity Hypoventilation Syndrome The Proceedings of the American Thoracic Society 5:218-225 (2008) Tsuneto Akashiba , Toshiki Akahoshi , Seiji Kawahara, Akihito Uematsu, Kazuhito Katsura , Shigeru Sakurai , Akira Murata 3, Hiroki Sakakibara 4,Kazuo Chin 5, Wataru Hida 6 and Hiroshi Nakamura 7 Clinical Characteristics of Obesityhypoventilation Syndrome in Japan: a Multi-center Study internal medicine Vol. 45 (2006) , No. 20 pp.1121-1125
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OHS Epidemiology
Babak Mokhlesi, Meir H. Kryger and Ronald R. Grunstein Assessment and Management of Patients with Obesity Hypoventilation Syndrome The Proceedings of the American Thoracic Society 5:218-225 (2008) Tsuneto Akashiba , Toshiki Akahoshi , Seiji Kawahara, Akihito Uematsu, Kazuhito Katsura , Shigeru Sakurai , Akira Murata 3, Hiroki Sakakibara 4,Kazuo Chin 5, Wataru Hida 6 and Hiroshi Nakamura 7 Clinical Characteristics of Obesityhypoventilation Syndrome in Japan: a Multi-center Study internal medicine Vol. 45 (2006) , No. 20 pp.1121-1125
©2009 Alraiyes
OHS Epidemiology
Babak Mokhlesi, Meir H. Kryger and Ronald R. Grunstein Assessment and Management of Patients with Obesity Hypoventilation Syndrome The Proceedings of the American Thoracic Society 5:218-225 (2008)
©2009 Alraiyes
OHS Diagnosis: Hypoventilation Obesity BMI > 30 Daytime sleepiness
Pulse OX
ABG
Hypoxia
CXR
High HCO3
High PaCO2
PFT
CBC TSH
Babak Mokhlesi, Meir H. Kryger and Ronald R. Grunstein Assessment and Management of Patients with Obesity Hypoventilation Syndrome The Proceedings of the American Thoracic Society 5:218-225 (2008)
©2009 Alraiyes
OHS Pathophysiology
Babak Mokhlesi, Meir H. Kryger and Ronald R. Grunstein Assessment and Management of Patients with Obesity Hypoventilation Syndrome The Proceedings of the American Thoracic Society 5:218-225 (2008)
©2009 Alraiyes
OHS Pathophysiology
Babak Mokhlesi, Meir H. Kryger and Ronald R. Grunstein Assessment and Management of Patients with Obesity Hypoventilation Syndrome The Proceedings of the American Thoracic Society 5:218-225 (2008)
©2009 Alraiyes
OHS pathophysiology
I. Rubinstein, MD; N. Zamel, MD; L. DuBarry, RPT; and V. Hoffstein, MD Airflow Limitation in Morbidly Obese, Nonsmoking Men Annals of internal medicine, 1990 - Am Coll Physicians
©2009 Alraiyes
OHS Pathophysiology
I. Rubinstein, MD; N. Zamel, MD; L. DuBarry, RPT; and V. Hoffstein, MD Airflow Limitation in Morbidly Obese, Nonsmoking Men Annals of internal medicine, 1990 - Am Coll Physicians
©2009 Alraiyes
OHS Pathophysiology
The control of the inter-apnea duration relative to the duration of the preceding apnea is an important component for the development of chronic hypercapnia in obstructive sleep apnea
Indu Ayappa, Kenneth I. Berger, Robert G. Norman, Beno W. Oppenheimer, David M. Rapoport, and Roberta M. Goldring Hypercapnia and Ventilatory Periodicity in Obstructive Sleep Apnea Syndrome Am J Respir Crit Care Med Vol 166. pp 1112–1115, 2002
©2009 Alraiyes
Pathophysiology
Indu Ayappa, Kenneth I. Berger, Robert G. Norman, Beno W. Oppenheimer, David M. Rapoport, and Roberta M. Goldring Hypercapnia and Ventilatory Periodicity in Obstructive Sleep Apnea Syndrome Am J Respir Crit Care Med Vol 166. pp 1112–1115, 2002
©2009 Alraiyes
Pathophysiology
The average apnea / inter-apnea duration ratio was directly related to the chronic awake PCO2
Indu Ayappa, Kenneth I. Berger, Robert G. Norman, Beno W. Oppenheimer, David M. Rapoport, and Roberta M. Goldring Hypercapnia and Ventilatory Periodicity in Obstructive Sleep Apnea Syndrome Am J Respir Crit Care Med Vol 166. pp 1112–1115, 2002
©2009 Alraiyes
Pathophysiology
Indu Ayappa, Kenneth I. Berger, Robert G. Norman, Beno W. Oppenheimer, David M. Rapoport, and Roberta M. Goldring Hypercapnia and Ventilatory Periodicity in Obstructive Sleep Apnea Syndrome Am J Respir Crit Care Med Vol 166. pp 1112–1115, 2002
©2009 Alraiyes
Pathophysiology
Babak Mokhlesi, Meir H. Kryger and Ronald R. Grunstein Assessment and Management of Patients with Obesity Hypoventilation Syndrome The Proceedings of the American Thoracic Society 5:218-225 (2008)
©2009 Alraiyes
Pathophysiology
Babak Mokhlesi, Meir H. Kryger and Ronald R. Grunstein Assessment and Management of Patients with Obesity Hypoventilation Syndrome The Proceedings of the American Thoracic Society 5:218-225 (2008)
©2009 Alraiyes
Pathophysiology
Babak Mokhlesi, Meir H. Kryger and Ronald R. Grunstein Assessment and Management of Patients with Obesity Hypoventilation Syndrome The Proceedings of the American Thoracic Society 5:218-225 (2008)
©2009 Alraiyes
Pathophysiology
Babak Mokhlesi, Meir H. Kryger and Ronald R. Grunstein Assessment and Management of Patients with Obesity Hypoventilation Syndrome The Proceedings of the American Thoracic Society 5:218-225 (2008)
©2009 Alraiyes
Mathematical model of Periodic breathing
A temporal V˙/Q˙ mismatch periodic breathing pattern is responsible for the hypercapnia
Bohr equation: PaCO2= constant x CO2 production/ventilation
D. M. Rapoport, R. G. Norman and R. M. Goldring CO2 homeostasis during periodic breathing: predictions from a computer model J. Appl. Physiol. 75(5): 2302- 2309, 1993.
©2009 Alraiyes
Mathematical model of Periodic breathing
D. M. Rapoport, R. G. Norman and R. M. Goldring CO2 homeostasis during periodic breathing: predictions from a computer model J. Appl. Physiol. 75(5): 2302- 2309, 1993.
©2009 Alraiyes
Mathematical model of Periodic breathing
D. M. Rapoport, R. G. Norman and R. M. Goldring CO2 homeostasis during periodic breathing: predictions from a computer model J. Appl. Physiol. 75(5): 2302- 2309, 1993.
©2009 Alraiyes
Mathematical model of Periodic breathing
D. M. Rapoport, R. G. Norman and R. M. Goldring CO2 homeostasis during periodic breathing: predictions from a computer model J. Appl. Physiol. 75(5): 2302- 2309, 1993.
©2009 Alraiyes
Apnea/inter-apnea ratio and hypercapnia exclusion of: 1) Periodic breathing provides a mechanism for acute hypercapnia in OSA, 2) Acute hypercapnia during periodic breathing may occur without a decrease in average Vmin, mainly secondary to temporal V˙/Q˙ mismatch 3) Compensation for CO2 accumulation during apnea/hypopnea may be limited by the duration of the interevent interval.
Kenneth I. Berger, Indu Ayappa, I. Barry Sorkin, Robert G. Norman, CO2 homeostasis during periodic breathing in obstructive sleep apnea J. Appl. Physiol. 88: 257–264, 2000.
©2009 Alraiyes
Apnea/inter-apnea ratio and hypercapnia
Kenneth I. Berger, Indu Ayappa, I. Barry Sorkin, Robert G. Norman, CO2 homeostasis during periodic breathing in obstructive sleep apnea J. Appl. Physiol. 88: 257–264, 2000.
©2009 Alraiyes
Apnea/inter-apnea ratio and hypercapnia
Kenneth I. Berger, Indu Ayappa, I. Barry Sorkin, Robert G. Norman, CO2 homeostasis during periodic breathing in obstructive sleep apnea J. Appl. Physiol. 88: 257–264, 2000.
©2009 Alraiyes
Kenneth I. Berger, Indu Ayappa, I. Barry Sorkin, Robert G. Norman, CO2 homeostasis during periodic breathing in obstructive sleep apnea J. Appl. Physiol. 88: 257–264, 2000.
©2009 Alraiyes
Apnea/inter-apnea ratio and hypercapnia
Kenneth I. Berger, Indu Ayappa, I. Barry Sorkin, Robert G. Norman, CO2 homeostasis during periodic breathing in obstructive sleep apnea J. Appl. Physiol. 88: 257–264, 2000.
©2009 Alraiyes
Apnea/inter-apnea ratio and hypercapnia
Kenneth I. Berger, Indu Ayappa, I. Barry Sorkin, Robert G. Norman, CO2 homeostasis during periodic breathing in obstructive sleep apnea J. Appl. Physiol. 88: 257–264, 2000.
©2009 Alraiyes
Apnea/inter-apnea ratio and hypercapnia effects of the event-tointerevent duration ratio on cycle CO2 balance: 1) When the event duration was short relative to the interevent duration (3:1), the cycle CO2 balance varied around zero and averaged 24 ml.
2) cycles with ratios 3:1 or more accounted for 80% of the total positive CO2 balance during the period of sleep.
Kenneth I. Berger, Indu Ayappa, I. Barry Sorkin, Robert G. Norman, CO2 homeostasis during periodic breathing in obstructive sleep apnea J. Appl. Physiol. 88: 257–264, 2000.
©2009 Alraiyes
Hypoventilation and PhOX2B
Ve´ ronique Dubreuil, Ne´ lina Ramanantsoa, Delphine Trochet, Vanessa Vaubourg, Jeanne Amie, Jorge Gallego A human mutation in Phox2b causes lack of CO2 chemosensitivity, fatal central apnea, and specific loss of parafacial neurons 2008 Jan 22;105(3):1067-72 Debra E. Weese-Mayer , Casey M. Rand , Elizabeth M. Berry-Kravis, Larry J. Jennings , Darius A. Loghmanee , Pallavi P. Patwari , Isabella Ceccherini Congenital central hypoventilation syndrome from past to future: Model for translational and transitional autonomic medicine Pediatr Pulmonol. 2009 Jun;44(6):521-35
©2009 Alraiyes
Hypoventilation and PhOX2B
Ve´ ronique Dubreuil, Ne´ lina Ramanantsoa, Delphine Trochet, Vanessa Vaubourg, Jeanne Amie, Jorge Gallego A human mutation in Phox2b causes lack of CO2 chemosensitivity, fatal central apnea, and specific loss of parafacial neurons 2008 Jan 22;105(3):1067-72 Debra E. Weese-Mayer , Casey M. Rand , Elizabeth M. Berry-Kravis, Larry J. Jennings , Darius A. Loghmanee , Pallavi P. Patwari , Isabella Ceccherini Congenital central hypoventilation syndrome from past to future: Model for translational and transitional autonomic medicine Pediatr Pulmonol. 2009 Jun;44(6):521-35
©2009 Alraiyes
OHS morbidities •OHS patients has: •congestive heart failure (odds ratio [OR], 9; 95% confidence interval [95% CI], 2.3–35) •angina pectoris (OR, 9; 95% CI, 1.4–57.1), •cor pulmonale (OR, 9; 95% CI, 1.4–57.1) •More hospitalization compared with patients with a similar degree of obesity but without hypoventilation •higher rates of admission to the intensive care unit . • Higher rates of invasive mechanical ventilation •hypertension (OR, 3.8; 95% CI, 1.5–9.8) •diabetes mellitus (OR,17.2; 95% CI, 7.3–40.7) •hypothyroidism (OR, 6.5; 95% CI, 2.4–17.5) •PAH compared with eucapneic patients w Babak Mokhlesi, Meir H. Kryger and Ronald R. Grunstein Assessment and Management of Patients with Obesity Hypoventilation Syndrome The Proceedings of the American Thoracic Society 5:218-225 (2008)
©2009 Alraiyes
OHS mortality
Babak Mokhlesi, Meir H. Kryger and Ronald R. Grunstein Assessment and Management of Patients with Obesity Hypoventilation Syndrome The Proceedings of the American Thoracic Society 5:218-225 (2008)
©2009 Alraiyes
OHS Treatment: O2 therapy •Half of the patient with OHS require supplemental nocturnal oxygen in addition to some form of PAP therapy. •The need for nocturnal and daytime oxygen therapy decreases significantly in patients adherent with PAP therapy
Babak Mokhlesi, Meir H. Kryger and Ronald R. Grunstein Assessment and Management of Patients with Obesity Hypoventilation Syndrome The Proceedings of the American Thoracic Society 5:218-225 (2008)
©2009 Alraiyes
OHS Treatment: Weight loss •In general weight loss results in: • Improvement in sleep-disordered breathing •Reduction in awake respiratory failure, •Improvement in lung function in patients with OHS •That can be achieved with bariatric surgery •On the other hand OHS patients are at increased risk of death related to gastric bypass surgery, in part because of the increased risk of postoperative respiratory failure and the development of pulmonary embolism. •Pre-op assessment and treatment with CPAP before surgery and directly after extubation reduce the post op respiratory failure.
Babak Mokhlesi, Meir H. Kryger and Ronald R. Grunstein Assessment and Management of Patients with Obesity Hypoventilation Syndrome The Proceedings of the American Thoracic Society 5:218-225 (2008)
©2009 Alraiyes
OHS Pharmacological treatment:
•Progesterone •Almitrine •Acetazolamide •Leptin replacement
Babak Mokhlesi, Meir H. Kryger and Ronald R. Grunstein Assessment and Management of Patients with Obesity Hypoventilation Syndrome The Proceedings of the American Thoracic Society 5:218-225 (2008)
©2009 Alraiyes
OHS Ventilation treatment: •Ventilatory support via tracheostomy for obesity-related respiratory failure has been used since the 1960s. •NPPV using a face or, later, nasal mask was regularly used in OHS from the late 1980s.
Babak Mokhlesi, Meir H. Kryger and Ronald R. Grunstein Assessment and Management of Patients with Obesity Hypoventilation Syndrome The Proceedings of the American Thoracic Society 5:218-225 (2008)
©2009 Alraiyes
OHS Ventilation treatment:
Kenneth I. Berger, MD, FCCP; Indu Ayappa, PhD; Barbara Chatr-amontri, MD; Apurva Marfatia, MD; I. Barry Sorkin, RRT; David M. Rapoport, MD; and Roberta M. Goldring, MD Obesity Hypoventilation Syndrome as a Spectrum of Respiratory Disturbances During Sleep CHEST 2001; 120:1231–1238
©2009 Alraiyes
OHS Ventilation treatment:
Kenneth I. Berger, MD, FCCP; Indu Ayappa, PhD; Barbara Chatr-amontri, MD; Apurva Marfatia, MD; I. Barry Sorkin, RRT; David M. Rapoport, MD; and Roberta M. Goldring, MD Obesity Hypoventilation Syndrome as a Spectrum of Respiratory Disturbances During Sleep CHEST 2001; 120:1231–1238
©2009 Alraiyes
OHS Ventilation treatment:
“in patient”
Hypoventilation Obesity BMI > 30 Daytime sleepiness Role out unstable medical status
Role out Contraindications to NPPV
Babak Mokhlesi, Meir H. Kryger and Ronald R. Grunstein Assessment and Management of Patients with Obesity Hypoventilation Syndrome The Proceedings of the American Thoracic Society 5:218-225 (2008)
©2009 Alraiyes
OHS Ventilation treatment:
“in patient”
Babak Mokhlesi, Meir H. Kryger and Ronald R. Grunstein Assessment and Management of Patients with Obesity Hypoventilation Syndrome The Proceedings of the American Thoracic Society 5:218-225 (2008)
©2009 Alraiyes
OHS Ventilation treatment:
“in patient”
Babak Mokhlesi, Meir H. Kryger and Ronald R. Grunstein Assessment and Management of Patients with Obesity Hypoventilation Syndrome The Proceedings of the American Thoracic Society 5:218-225 (2008)
©2009 Alraiyes
My patient •Last moment consult •PSG ordered •Sent home on CPAP 7 cmH2O
Babak Mokhlesi, Meir H. Kryger and Ronald R. Grunstein Assessment and Management of Patients with Obesity Hypoventilation Syndrome The Proceedings of the American Thoracic Society 5:218-225 (2008)
©2009 Alraiyes
OHS
Questions??
©2009 Alraiyes
OHS
Thank You
©2009 Alraiyes