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

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©2009 Alraiyes

Consult
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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
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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

©2009 Alraiyes

PMHx
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A.fib CAD CHF HTN DM COPD chronically on 3L oxygen; no PFTs in system OSA

©2009 Alraiyes

Medications
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ASA Carvedilol Lasix Glipizide NPH Lisinopril Clariitn Omeprazole Simvastatin Coumadin

©2009 Alraiyes

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

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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 \ 98

143

___|___|____/ \ 4.8 | 38 | 1.4
HCO3 Jun 2003 24 Aug 2004 23 Jan 2005 25

138

47

PH: 7.35 PaCO2: 64.3 PaO2: 87 HCO3: 37 110

Mar 2005 26

Jul 2006 30

Dec 2006 28

Apr 2008 30

Mar 2009 33

Jul 2009 32

Sep 2009 37

©2009 Alraiyes

2D-Echo
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7/09-preserved EF, moderate to severe LVH, LA and RA mod dilated, trace MR, mild TR, no AV stenosis; RV pressures are normal

©2009 Alraiyes

Summary
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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.

©www.endotext.org

©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

©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

©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

Hypoxia

High HCO3

High PaCO2

Pulse OX

ABG

CXR

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:
Hypoventilation Obesity BMI > 30 Daytime sleepiness Role out unstable medical status

“in patient”

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

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