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Otto Schoch, PD Dr. Leitender Arzt Pneumologie und Zentrum für Schlafmedizin Kantonsspital St.Gallen Obesity-Hypoventilation and Sleep-Apnea
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WHO Grad I = BMI 30-35 kg/m 2 WHO Grad II = BMI 35-40 kg/m 2 WHO Grad III = BMI >40 kg/m 2 Definition Obesity Stunkard: obese > Silhouette 6
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Obesity 2012 Major public health Problem Since1980 > Adipositas has dobbeled: more CV Diseases, Diabetes, Arthrosis, Carcinoma 5. frequent cause of death world wide Risks increase with BMI Energy imbalance between calories consumed and calories expended WHO facts sheet 5/ 2012
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Prevalence of BMI >30 kg/m 2 : 25% Switzerland 2010: 14% OSAS patients KSSG (1756): 51% European Sleep Apnea Database (5103): 50.7% (OSAS KSSG >35 kg/m 2 : 25%)
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Otto Schoch Kantonsspital St.Gallen
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Otto Schoch Kantonsspital St.Gallen AJRCCM 2012; 185: 241-3
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Am J Respir Crit Care Med Vol 179. pp 320–327, 2009 Weight and AHI: Study from Finland mild OSAS, AHI 5-15/h 81 of 630 referrals weight reduction: if > -15 kg: 85% cured !
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Sutherland K et al. Thorax 2011;66:797-803 ©2011 by BMJ Publishing Group Ltd and British Thoracic Society Surface reconstructions (CT scans) before and after weight loss (A)head and neck region (B)the upper airway. -19 kg Gewicht (18% KG) + 5.1 cm3 Volumen Pharynx AHI: 55.9 /h auf 15.1 /h.
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> Korrektur der Apnoen > CO 2 Anfall reduziert Sullivan CE, Berthon-Jones M, Issa F, Eves L. Obstructive Sleep Apnea: CPAP Keeps upper airway open Constant pressure during breath cycle http://www.nejm.org/doi/full/10.1056/NEJMicm1212352?query=TOC
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CPAP for OSAS: Results KSSG Adherence at 10y related to OSAS severity and symptoms (ESS) BMI does not perdict adherence (n=1756) unpublished
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CPAP for OSAS: Adherence Psychological factors: Stepwise approach Type of mask, mask fit, face masks Technical: Humidification Expiratory pressure release Support interventions, eg Telemedicine Regular follow-up checks, technical Effectivity: Pulse oximetry, CO 2
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Obesity Hypoventilation OHS Hypoventilation = Wach-Pa CO2 > 6 kPa (>45mmHg) OHS = BMI > 30kg/m 2 + Hypoventilation No pulmonary or neuromuscular disease Increase in prevalence with increase in BMI BMI >50 kg/m 2 = > 50% OHS Prodromal stage: Nocturnal Hypoventilation Amanda Piper, Ronald Grunstein: AJCCM 2011,183: 292-8
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AJCCM 2011,183: 292-8; Respirology 2012, 17: 402–411
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J Appl Physiol 2010, 108: 199–205, AJCCM 2011, 183: 292-8 OHS Eucapnic Obesity Thorax 2009; 64: 719–25 Expiratory Flow Limitation and intrinsic PEEP. CPAP abolishes PEEPi and reduces neural respiratory drive
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Ventilatory drive (VD) in OHS VD in increased in obesity vs normal weight No correlation of VD with BMI OHS: hypercapnic & hypoxic VD markedly reduced (wake) Reduction parallels HCO 3- elevation Sleep deprivation: reduced ventilatory response to hypercapnia 2 weeks of CPAP improve VD Acetazolamide increases VD Respirology (2012) 17, 402–411
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Respir Care 2010;55(11):1442–1448 BMI Terzilen: 30-36, 36-42, 42-60 kg/m 2 HCO 3 Terzilen: 26-31, 31-37, 37-44 mmol/L HCO 3- Mit / ohne Acetazolamid (Diamox) Ventilatory drive in OHS
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Anesthesiology 2012; 117:188 –205
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Prognosis of OHS
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Screening for OHS OSAS patients at diagnosis BMI 30-40 kg/m 2 : 10% OHS BMI 40-50 kg/m 2 : 20% OHS BMI >50 kg/m 2 : 50% OHS Pulsoxy <92% aBGA in OHS: PaO 2 <70 mm Hg (10kPa) HCO 3 >27 mEq/L: Sensitivity 92%, specificity 50% continuous transcutaneous CO 2 Monitoring very sensitive > Prodromal stage of OHS (eg in REM)
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Positive Airway Pressure for OHS CPAP: High pressure levels to overcome upper airway resistance Oxymetry in the first night: 30-50% of OHS still at SpO2 <90% Adherence is a better predictor of paCO 2 decrease than CPAP vs bilevel NIV J Clin Sleep Med 2006;2:57–62
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NIV for OHS: Technical issues CPAP vs NIV Supplemental Oxygen NIV Mode: S / ST / T How to define optimal frequency ? How to define optimal EPAP level / Automatic EPAP? Role of Average Volume Assured PS with IPAP range (Storre, Chest 2006) > Need for measuring PSG / PG / ptCO2
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CPAP or bilevel NIV ? 1 Radomized controlled trial Thorax 2008;63:395–401.
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CPAP or bilevel NIV ? Thorax 2008;63:395–401.
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Supplemental O 2 for OHS Double-edged sword Risk of CO 2 increase with O 2 MV decreases considerably with 100% O 2 Assess reason for low O 2 –Pulmonary hypertension, CTEPH, COPD –Heart failure Monitor effect on CO 2 and HCO 3 Consider Acetazolamide if HCO 3 high CHEST / 139 / 5 / MAY, 2011: 975 f
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Long term results: NIV for OHS CHEST 2010; 138(1):84–90
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OHS with and without supplemental O2 CHEST 2010; 138(1):84–90
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S-Mode / ST-Mode low back-up / ST-Mode high back-up ? A: Central Apnea Hypopnea Index (N/hour); B: Mixed Apnea Hypopnea Index Chest 2012, e-pub
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A- Central hypopnea under NPPV in S/T mode with high BURR (RR: 20/min). Note disappearance of thoraco-abdominal movements during the event and resumption of flow with resumption of respiratory movements; ventilator switches to BURR and continues to pressurise, inducing small spikes on the flow curve. Drop in SpO2 ensues. Chest 2012, e-pub
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B- Obstructive hypopnea under NPPV in S/T mode with low BURR (RR: 11/min.). Flow decreases drastically in spite of persistent pressurisations by the ventilator, which has switched to BURR. Thoracic and abdominal movements show phase opposition and a gradual increase in inspiratory efforts until airflow resumes. The event induces a drop in SpO2. Chest 2012, e-pub
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C- Mixed apnea under NPPV in Spontaneous mode. Two consecutive events associated with drops in SpO2. Total interruption of airflow, with cessation of thoraco- abdominal movements during the initial part of the event (central component), followed by resumption of thoraco-abdominal movements with phase opposition (obstructive component). No pressurisation occurs during the event because ventilator is in S mode. Chest 2012, e-pub
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Treating chronic OHS: how I do it Always start with nasal or oronasal CPAP Re-assess after 1 month of treatment: adherence and night-time oximetry If night-SpO 2 <92%: aBGA, LuFu, 6MWT, PG/PSG under CPAP with ptCO2, Echo Refractory OHS: Switch to NIV, Consider Acetazolamide PAH suspected: Right heart catheter, antikoagulation, (specific treatment?)
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Haemodynamic effects of non-invasive ventilation in patients with OHS 30 OHS patients Echo: 43% systolic pulmonary hypertension 6 months NIV sPAP from 58±11 to 44±12 mmHg (p<0.05) 6MWT from 350±110 to 426±78m (p<0.01) Respirology. 2012 Nov;17(8):1269-74
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