1. NON INVASIVE VENTILATION IN OBESE HYPOVENTILATION SYNDROME:
CPAP versus BIPAP?
Antonio M. Esquinas MD, PhD, FCCP, Internacional Fellow AARC
Intensive Care and Non Invasive Ventilatory Unit
Hospital Morales Meseguer.
Murcia, Spain
Director  International School of Non-invasive mechanical Ventilation
President International Association of NIV and Ibero American  Association of  Bioethics in NIV

2. Reasons for decisions
Key determinants
OHS-Pathophysiology determinants
Interactions OHS-CPAP-BIPAP
Determinants interactions: key methodology aspects
Integration CPAP and BIPAP mode in OHS diseases
Summary CPAP-BIPAP results
Strategy CPAP-key factors
Strategy BIPAP-key factors
Recommendations for clinical practice decisions

3. Key aspect:
OHS
Health
Care
Resources
CPAP vs BiPAP
OHS-

4. Obesity Hypoventilation Syndrome Consequences

5. Key aspects
Obesity
Consequences
CPAP vs BiPAP
OHS-

6. Key aspect:
OHS AND OSA
Prevalence-2
CPAP vs BiPAP
OHS-

7. OHS, OSA COPD, Obesity, Overlap Diseases

8. Key aspect: OHS, OSA COPD, Obesity, Overlap Diseases
Clinical, methodology
implications
CPAP vs BiPAP
OHS-
COPD
Obese
Obesity Hypoventilation
OSA

9. OHS Respiratory Failure Pathways-Influence

10. Obesity-Mechanism-Lung disease
Key aspect:
OHS
Mechanisms
CPAP vs BiPAP
OHS-

11. Differences: normal, obesity and hypoventilation
Key aspect:
OHS
Volume
Failure:
Pathways
CPAP vs BiPAP
OHS-

12. Pathways daytime hypercapnia Chronic Hypercapnia

13. Key aspect:
OHS
Lung-effects
CPAP vs BiPAP
OHS-

14. Hypoxemia during CPAP therapy

15. Key aspect:
Obesity-OHS
Hypoxemia during
CPAP therapy
CPAP vs BiPAP
OHS-

16. Summary OHS-CPAP-vs BiPAP

17. Key aspect:
Summary Studies
OHS
Prevalence-1
CPAP vs BiPAP
OHS-

18. Key aspect:
OHS
Arterial
Blood
Gases
Response-2
CPAP vs BiPAP
OHS-

19. Key aspect: OHS Arterial Sleep Parameters-3 CPAP vs BiPAP OHS-
NPPV-Short-term and long term positive airway pressure therapy improve AHI and oxygen saturation during Sleep in OHS

20. Key aspect: OHS PulmonaryFunction-4 CPAP vs BiPAP OHS-
NPPV-Short-term and long term positive airway pressure therapy on Pulmonary Function
Key aspect:
OHS
PulmonaryFunction-4
CPAP vs BiPAP
OHS-

21. Key aspect: OHS %, TST response-5 SpO <90% CPAP vs BiPAP OHS-
NPPV-Short-term and long term positive airway pressure therapy improve % TST response with SpO2 in OHS
Key aspect:
OHS
%, TST response-5
SpO <90%
CPAP vs BiPAP
OHS-

22. Summary
Results -1
CPAP vs BiPAP
OHS-1

23. Summary
Results -2
CPAP vs BiPAP
OHS-2

24. Summary
Results -3
CPAP vs BiPAP
OHS-3

25. OHS Short and Long Term Effects

26. Key aspect:
OHS
Short and Long Term
Effects-2
CPAP vs BiPAP
OHS-

27. Key aspect: OHS Survival Months CPAP vs BiPAP OHS- (18 months)
Months after diagnosis of OHS

28. Risk of Mortality OHS CPAP-vs BiPAP

29. Key aspect: Obesity-OHS Long-term Outcome OHS-5 (6 months)
Factors influencing long-term survival in OHS
Key aspect:
Obesity-OHS
Long-term Outcome
OHS-5 (6 months)
Relative risk of
death
CPAP vs BiPAP
OHS-

30. Methodology and Practice OHS CPAP and PAP

31. Initial therapy, Acute, chronic Situations Ph/pCO2 trends

32. Key aspect:
OHS
Initial therapy,
Acute, chronic
Situations
Ph/pCO2 trends
CPAP vs BiPAP
OHS-

34. Noninvasive Ventilation

35. Key aspect: Inspiratory Muscle Activite- Methodology-2 Pressure-time
products of diaphragm
OHS
OSA
Simple Obese
CPAP vs BiPAP
OHS-
OHS
OSA
Obese
OHS
OSA
Obese

36. Backup Respiratory Rate factor

37. Key aspect:
Backup Respiratory Rate factor
CPAP vs BiPAP
OHS-

38. Key aspect: CPAP vs BiPAP OHS- Backup Respiratory Rate factor-3
Case A=central apnea-hypopnea Case B=Mixed apnea-hypopnea
(No. of events/h)
(No. of events/h)
BURR: Backup Respiratory Rate

39. OHS Response Hypercapnic Failure after PAP therapy

40. Hypercapnic Failure after PAP therapy
Inadequate adherence IPAP therapy
Inadequate PAP titration
Sleep disordered breathing other than OSA
(central hypoventilation)
Associated respiratory disease
(COPD, interstitial lung disease)
Metabolic alcalosis ( ie; due to high doses of loop diuretics)
Key aspect:
Obesity-OHS
Hypercapnic
Failure
after PAP therapy
CPAP vs BiPAP
OHS-

41. Compliance and non compliance

42. Key aspect:
OHS
Interface
CPAP vs BiPAP
OHS-

43. Acute Hypercapnic Respiratory Failure
Interface- clinical-technical factors

44. Key aspect:
OHS
Compliance
And non compliance
CPAP vs BiPAP
OHS-

45. Summary and conclusions for practical decisions
OHS
CPAP versus BIPAP

46. 2-OHS Clinical- Methodology Use of Health care resources 1-Obesity
It is a global disease. Increasing prevalence of OHS-OSA overlap
2-OHS
3-Overlap disease associations
OSA (*) predominat failure during sleep), OHS, COPD, CHF
(*) comorbidities ( cardiovascular)
Clinical- Methodology
Lung mechanics-Volume –Failure-Pathways-Expiratory reserve
Implications-Initial therapy
Acute (non PSG study) Chronic ( PSG study)
Situations
Hypoxemic pH/pCO2 trends

47. Hypoxemic---------------------------------------Ph/pCO2 trends 1
Situations
Hypoxemic Ph/pCO2 trends 1
(OSA-OHS= Acute hypercapnic during Sleep)
(CO3h trends) 2
OHS= Awake daytime hypercapnic
Upper airways compromise-Sleep
Hypercapnic mechanisms
Leptin-factor
PCO2 trends-follow up

48. Noncompliance Compliance Short-term Long term effects
NPPV-Interface-Pressure positive selection
Goals theory
[Gas exchange, Sleep parameters, Pulmonary function, TST SatO2 response]
CPAP BiPAP
Hypoxemic Hypoxemic-hypercapnic
O2 therapy
hypercapnic
2-Respiratory breathing patterns
3-Apnea –hypopnea limitation--- (Back up respiratory rate, ST mode)
Noncompliance Compliance
Hypercapnic failure after IPAP strategy
Low VT?
Consider AVAPS
Short-term Long term effects
Mortality