Pulmonary in the heavy weights

OSA and beyonds

Somprasong Liamsombut M.D.

Asst professor Visasiri Tantrakul M.D.
Division of Sleep Medicine, Department of Medicine
Ramathibodi hospital
Mahidol University
Obesity
• “Abnormal or excessive fat accumulation that may impair health”
• Most common metabolic disease in the world, becoming one of the
leading priorities for WHO.
• The prevalence of obesity has reached epidemic proportions and
continues to escalate.
• Between 1980 and 2004, the prevalence ↑from 15% to 33% in adults
and↑from 5.5% to 17% in children
• Recent projections based on the National Health and Nutrition Examination
Surveys (NHANES) predict that if the current trends continue, more than half
(51.1%) of US adults are likely to be obese and 86.3% are likely to be
overweight or obese by 2030.
Ogden CL, Yanovski SZ, Carroll MD, et al.
The epidemiology of obesity. Gastroenterology 2007; 132(6):2087–102
Wang Y, Beydoun MA, Liang L, et al. Will all Americans become overweight or obese?
Estimating the progression and cost of the US obesity epidemic. Obesity (Silver Spring) 2008;16(10):2323–30
 Obesity Prevalence, Gross Domestic Product (GDP) per Capita and
Percentage of Urban Population in Thailand between 1991 and 2014

Teerawattananon, Y. and A. Luz. 2017. Obesity in Thailand. ADBI Working Paper 703.
Obesity Definition

18.5-22.9
23.0-24.9
25.0-29.9
30.0-39.9
Health Risks associated with Obesity
• Type 2 Diabetes
• Risk for diabetes increases linearly with BMI
• Overweight adolescents had a nearly a 2x higher risk of IFPG.
• Dyslipidemia
• ↑triglycerides, ↓HDL and ↑LDL
• Hypertension
• Enhanced sympathetic tone, RAS activation, ↑insulin, ↑leptin and impaired renal function
• Coronary artery disease
• ↑Markers of inflammation, endothelial dysfunction,
• even after correction for other known risk factors
• Obstructive sleep apnea
• Non-alcoholic fatty liver disease
• App. 20% of obese pt
• Cancer
• Increases in death rates for all cancers combined.

Catenacci VA et al. Clin Chest Med 30 (2009) 415–444

Effect on lung volumes
• Reduction in Expiratory Reserved Volume (ERV)
• The most common and consistent indicator of obesity
• Displacement of the diaphragm into the thorax
• Mass loading effect on both the thorax and within the upper abdomen
• Reduction in Functional Residual Capacity (FRC)
• Mostly explained by the reduction in ERV
• Often markedly reduced approaching residual volume (RV)
• When below closing capacity (CC) → basal atelectasis
• Extremes of lung volumes such as RV and total lung capacity (TLC)
usually preserved
Courtesy of Aboussouan LS. M.D.
Sleep disorder center, CCF
Effect of Obesity on Lung Volumes

IRV
TV
ERV
RV
CV
CC

FRC

Normal Obese

Courtesy of Aboussouan LS. M.D.

Sleep disorder center, CCF
Effect of
Obesity
on
Lung
Volumes

Paul D Robinson.
Paediatric Respiratory Reviews 15 (2014) 219–226
F Crummy et al. Obesity and the lung2. Thorax 2008;63:738–46
 Obesity
and
Exercise Capacity

https://www.weightofthenation.org/symptoms-or-signs-of-obesity/
Effect on Cardiopulmonary Exercise Testing

Paul D Robinson.
Paediatric Respiratory Reviews 15 (2014) 219–226
 Obesity
displaces
the ṼO2
-work
rate
relation
upward

Wasserman K, et al. Principles of exercise testing and interpretation.

4th edition. Philadelphia: Lippincott Williams & Wilkins; 2005. p. 83
Effects on Airway
• Increase in airway resistance
• Breathing at low lung volumes
• Normal specific airway conductance
• May not be entirely explainable
• Increase in airway responsiveness to methacholine
• Reduced airway diameter → altered airway structure an function
• Stiffer airway smooth muscle
• Obesity associated inflammatory cytokines may also play the role
 Beuther DA, Weiss ST, Sutherland ER.
Am J Respir Crit Care Med Vol 174. pp 112–9, 2006
Obesity ?Asthma
 Steroid
Th1 related resistance,
inflammation reduced
in the airways expression of
MKP1, TNF-ꭤ

Increased IL-17
leptin, associated
decreased inflammation
adiponectin in the airways

Low L arginine/
Decreased FRC
ADMA ratio,
increased and ERV due
oxidative stress to abdominal
and lower NO adiposity

Baffi et al. Asthma Research and Practice (2015) 1:1

Obesity and pulmonary embolism
• PE → the third most frequent cardiovascular disorder, however,
often overlooked
• Various abnormalities of hemostasis
• Increased plasminogen activator inhibitor
• Increased platelet aggregability
• higher levels of von Willebrand factor, plasma fibrinogen, factor VII, and factor VIII
• Increased circulating microparticles Stein PD, Goldman J. Clin Chest Med 30 (2009) 489–93

• The relative risk for PE, comparing obese

patients with nonobese patients, was
2.18, and for DVT, it was 2.50.
Stein PD, Beemath A, Olson RE. Am J Med 2005;118:978–80
Relative Risk of Recurrent Venous
Thromboembolism According to
Categories of Body Weight

Eichinger S, Hron G, Bialonczyk C, et al. Arch Intern Med. 2008;168(15):1678-83

Obesity and pulmonary hypertension
• Pulmonary hypertension
▪ Defined by mPAP > 20 mmHg
Simonneau G, et al. Eur Respir J 2019; 53: 1801913

• Prevalence of PH in obese
▪ A retrospective single center - 5% of otherwise healthy individuals with a BMI
> 30 kg/m2 had PASP greater than 50 mm Hg on echocardiogram
B. M. McQuillan, et al. Circulation.2001(104)23pp. 2797–802

▪ 38% of PH patients defined by mPAP > 20 mmHg on RHC were obese

Frank RC. Et al. J Am Heart Assoc. 2020;9:e014195
Clinical classification of pulmonary hypertension

European Heart Journal (2022) 43, 3618–3731

Obstructive Sleep Apnea

https://health.clevelandclinic.org/sleep-testing-at-home-vs-in-the-lab/
Obstructive Sleep Apnea
• Obstructive Sleep Apnea : OSA
A medical disorder characterized by repeated episodes of an intermittent decrease or absence of
inspiratory air flow due to upper airway closure during sleep
• Obstructive Sleep Apnea (Hypopnea) Syndrome : OSA(H)S
▪ 5 or more episodes of apnoea or hypopnoea per hour of sleep with associated symptoms
▪ 15 or more obstructive apnea-hypopnea events per hour of sleep regardless of associated
symptoms
• The Wisconsin Sleep Cohort data
For moderate-to-severe OSAS
10 % in men and 3 % in women among the ages of 30–49 years
17 % in men and 9 % in women among the ages of 50–70 years
Nearly 1 in 15 affected by at least moderate sleep apnea
Peppard et al. Am J Epi 2013
Beaudin et al. Exp Physiol 102.7 (2017) pp 743–63
Prevalence of Obstructive Sleep Apnea

C.V. Senaratna et al. / Sleep Medicine Reviews 34 (2017) 70e81

OSA

JC Carberry, J Amatoury, DJ Eckert. Personalized

Management Approach for OSA.Chest. 2018
Signs and Symptoms in Obstructive Sleep Apnea Syndrome

Chokroverty S. Approach to the patients with sleep complaints.

In: Chokroverty S, editor. Sleep Disorder Medicine 4th ed. 2017
 Is the patient clinically high suspicious for OSA ?

1-2 = Low risk 3-4 = Intermediate risk > 5 = High risk

Physical Findings in Patients with
Obstructive Sleep Apnea Syndrome
• Obesity in the majority of patients (70 %)
• Increased body mass index (BMI) [body weight in kg/height in m2]
In Thailand ; ≥ 25 considered obesity
• Increased neck circumference (>17” in men and >16“ in women)
• Large edematous uvula
• Low-hanging soft palate
• Large tonsils and adenoids (especially in children)
• Retrognathia
• Micrognathia
• Polycythemia
• Hypertension
• Cardiac arrhythmias
• Evidence of congestive heart failure
Diagnostic criteria for OSAS
 Best Practice Example/
The ESRS Wake-Up bus drivers
http://www.esrs.eu/home.html?no_cache=1
OSA Treatment
OSA Treatments
• Maintain upper airway patency during sleep
• Restore sleep continuity
• Retain adequate gas exchange
• Improve quality of life
• Improved sleepiness
• Improved neurocognitive function
• Psychological aspects Kushida CA et al.Sleep. 2006 Mar;29(3):375-80

• Lowering blood pressure Cristiano Fava et al. CHEST 2014; 145(4):762–771

• Decrease all cause mortality Marin, et al. Lancet. 2005

PAP Therapy
PAP Therapy
• Provide “pneumatic splinting” of the upper airway
• The first line, gold standard treatment for OSA
• Very high efficiency if tolerated
• Long term adherence rate of 60-70%
• Not as costly as surgery
• Reduce blood pressure, improve quality of life
and long term survival
• Can re-titrate the pressure if the patient’s condition changes

Cristiano Fava et al. CHEST 2014; 145(4):762–771

Kushida CA et al.Sleep. 2006 Mar;29(3):375-80
Tregear S et al. SLEEP 2010;33(10):1373-80
End of Part I
to be continued