2 Pickwickian SyndromeObstructive sleep apnea was called the Pickwickian syndrome in the past because Joe the Fat Boy who was described by Charles Dickens in the Pickwick papers had typical features with snoring, obesity, sleepiness and “dropsy”.
10 Mechanism of OSASThe upper airway dilating muscles,like all striated muscles-normally relax during sleep.In OSAS, the dilating muscles can no longer successfully oppose negative pressure in the airway during inspiration.Apneas and hypopneas are caused by the airway being sucked and closed on inspiration during sleep.
15 Features of Excessive Sleepiness Motor vehicle crashesWork related accidentsImpaired school or work performanceMarital problemsMemory and concentration difficultiesDepressionImpaired quality of life
16 OHS,OSA & Cardiovascular Diseases Uncontrolled HTN- 83% have OSAH; activation of sympathetic drive.Acute coronary syndrome % has OSACardiac arrhythmias mostly AfHeart FailureSudden cardiac deathStroke
17 OSA,OHS and DMPatients from the sleep clinic with AHI>10 are much more likely to have impaired glucose tolerance and diabetes(Meslier et al Eur Respir J 2003)
18 Diagnosis A good sleep history Assessment of obesity, oral cavity Assessment of possible predisposing causes: HTN, hypothyroidism, acromegaly andPolysomnography: gold standard tool
21 Apnea-Hypopnea IndexApnoea-hypopnoea index (AHI)= number of apnea/hypopnea per hour of sleepAHI<5 NormalAHI 5-15 Mild OSAAHI Moderate OSAAHI >30 Severe OSA
22 OHS: Treatment PAP (CPAP or BiPAP) Oxygen therapy Surgery No standard protocol for titrationOxygen therapySurgeryTracheostomyWeight reductionPharmacotherapyMedroxyprogesteroneAcetazolamide
23 Behavioral Treatments Attain an ideal body weightSleep on the sideAvoid sedative medication before sleepAvoid being sleep deprivedAvoid alcohol before sleepElevate the head of the bedPromptly treat colds and allergiesAvoid large meals before bedtimeStop smoking
24 Body Position Strategies- Raise HOB Avoid supine position Tennis ball in pajamasBackpacks
25 CPAP Therapy Works as a pneumatic Splint 1st choice of treatment in moderate to severe OSAHSSuccess rate %Long term compliance 60-70%Retitrate pressure if needed
26 Oral Appliances MAD □ Not as effective as CPAP, TRD □ Not yet available in Iran□ Appropriate first-line treatment for Mild OSA, primary snoring, upper airway resistance syndrome ( UARS )□ Not as effective as CPAP,52% OSA have AHI<10%□ Young, non-obese□ Second line therapy for moderate-severe OSA□ Patient’s choice - Not tolerating / refuse to use CPAP, or are not surgical candidatesMADTRD
27 Medical Treatments Weight loss Pharmacological Oxygen therapy Nasopharynegeal intubationNasal CPAPBiLevel CPAPAutomatic CPAPOral AppliancesAtrial Pacing
28 Oxygen Therapy Improves oxygen saturation during sleep May prolong apneic episodesReduces cardiac arrythmiasUseful additive treatment with CPAPRarely reduces apneic episodesCan improve daytime sleepinessMay cause CO2 retention
29 Pharmacological Therapy ProtriptylineMedroxyprogesteroneFluoxetineAntihistaminesNasal SteroidsTheophyllineAcetazolamideModafinilMagalang UJ et al, 2003
30 ConclusionWith the increasing problem of obesity, the impact of undetected OHS & OSAS as a public health burden cannot be undermined among our population,It merits appropriate preventive and treatment strategies.
31 referencesMokhlesi, B., Tulaimat, A. (2007), “Recent Advances in Obesity Hypoventilation Syndrome”, Chest 132 (4),Weinberger, S.E., Drazen, J.M., “Disturbances in Respiratory Function”, in Kasper et al (eds), Harrison’s Principles of Internal Medicine (16th Edition), New York: McGraw-Hill, ppGuyton, A.C., Hall, J.E. (2000), Textbook of Medical Physiology (10th edition), Philadelphia: W.B. Saunders.