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Brown LK. Targeting Hypercapnia in Chronic Lung Disease and Obesity Hypoventilation: Benefits and Challenges. Sleep Med Clin 2024; 19:357-369. [PMID: 38692758 DOI: 10.1016/j.jsmc.2024.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Abstract
Hypoventilation is a complication that is not uncommon in chronic obstructive pulmonary disease and calls for both medical treatment of the underlying disease and, frequently, noninvasive ventilation either during exacerbations requiring hospitalization or in a chronic state in the patient at home. Obesity hypoventilation syndrome by definition is associated with ventilatory failure and hypercapnia. It may or may not be accompanied by obstructive sleep apnea, which when detected becomes an additional target for positive airway pressure treatment. Intensive research has not completely resolved the best choice of treatment, and the simplest modality, continuous positive airway pressure, may still be entertained.
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Affiliation(s)
- Lee K Brown
- Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Internal Medicine, University of New Mexico School of Medicine, Albuquerque, NM, USA.
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2
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Aung O, Amorim MR, Mendelowitz D, Polotsky VY. Revisiting the Role of Serotonin in Sleep-Disordered Breathing. Int J Mol Sci 2024; 25:1483. [PMID: 38338762 PMCID: PMC10855456 DOI: 10.3390/ijms25031483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 01/22/2024] [Accepted: 01/24/2024] [Indexed: 02/12/2024] Open
Abstract
Serotonin or 5-hydroxytryptamine (5-HT) is a ubiquitous neuro-modulator-transmitter that acts in the central nervous system, playing a major role in the control of breathing and other physiological functions. The midbrain, pons, and medulla regions contain several serotonergic nuclei with distinct physiological roles, including regulating the hypercapnic ventilatory response, upper airway patency, and sleep-wake states. Obesity is a major risk factor in the development of sleep-disordered breathing (SDB), such as obstructive sleep apnea (OSA), recurrent closure of the upper airway during sleep, and obesity hypoventilation syndrome (OHS), a condition characterized by daytime hypercapnia and hypoventilation during sleep. Approximately 936 million adults have OSA, and 32 million have OHS worldwide. 5-HT acts on 5-HT receptor subtypes that modulate neural control of breathing and upper airway patency. This article reviews the role of 5-HT in SDB and the current advances in 5-HT-targeted treatments for SDB.
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Affiliation(s)
- O Aung
- Department of Medicine, Johns Hopkins University, Baltimore, MD 21224, USA; (O.A.); (M.R.A.)
- Medical College of Wisconsin, Milwaukee, WI 53226, USA
- Department of Anesthesiology and Critical Care Medicine, George Washington University, Washington, DC 20037, USA
| | - Mateus R. Amorim
- Department of Medicine, Johns Hopkins University, Baltimore, MD 21224, USA; (O.A.); (M.R.A.)
- Department of Anesthesiology and Critical Care Medicine, George Washington University, Washington, DC 20037, USA
| | - David Mendelowitz
- Department of Pharmacology and Physiology, George Washington University, Washington, DC 20037, USA;
| | - Vsevolod Y. Polotsky
- Department of Medicine, Johns Hopkins University, Baltimore, MD 21224, USA; (O.A.); (M.R.A.)
- Department of Anesthesiology and Critical Care Medicine, George Washington University, Washington, DC 20037, USA
- Department of Pharmacology and Physiology, George Washington University, Washington, DC 20037, USA;
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Baglyas S, Valkó L, Móró V, Podmaniczky E, Czövek D, Makan G, Gingl Z, Gál J, Hantos Z, Lorx A. Using intra-breath oscillometry in obesity hypoventilation syndrome to detect tidal expiratory flow limitation: a potential marker to optimize CPAP therapy. BMC Pulm Med 2023; 23:477. [PMID: 38017501 PMCID: PMC10685591 DOI: 10.1186/s12890-023-02777-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 11/21/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND Continuous positive airway pressure (CPAP) therapy has profound effects in obesity hypoventilation syndrome (OHS). Current therapy initiation focuses on upper airway patency rather than the assessment of altered respiratory mechanics due to increased extrapulmonary mechanical load. METHODS We aimed to examine the viability of intra-breath oscillometry in optimizing CPAP therapy for OHS. We performed intra-breath oscillometry at 10 Hz in the sitting and supine positions, followed by measurements at increasing CPAP levels (none-5-10-15-20 cmH2O) in awake OHS patients. We plotted intra-breath resistance and reactance (Xrs) values against flow (V') and volume (V) to identify tidal expiratory flow limitation (tEFL). RESULTS Thirty-five patients (65.7% male) completed the study. We found a characteristic looping of the Xrs vs V' plot in all patients in the supine position revealing tEFL: Xrs fell with decreasing flow at end-expiration. Intra-breath variables representing expiratory decrease of Xrs became more negative in the supine position [end-expiratory Xrs (mean ± SD): -1.9 ± 1.8 cmH2O·s·L- 1 sitting vs. -4.2 ± 2.2 cmH2O·s·L- 1 supine; difference between end-expiratory and end-inspiratory Xrs: -1.3 ± 1.7 cmH2O·s·L- 1 sitting vs. -3.6 ± 2.0 cmH2O·s·L- 1 supine, p < 0.001]. Increasing CPAP altered expiratory Xrs values and loop areas, suggesting diminished tEFL (p < 0.001). 'Optimal CPAP' value (able to cease tEFL) was 14.8 ± 4.1 cmH2O in our cohort, close to the long-term support average of 13.01(± 2.97) cmH2O but not correlated. We found no correlation between forced spirometry values, patient characteristics, apnea-hypopnea index and intra-breath oscillometry variables. CONCLUSIONS tEFL, worsened by the supine position, can be diminished by stepwise CPAP application in most patients. Intra-breath oscillometry is a viable method to detect tEFL during CPAP initiation in OHS patients and tEFL is a possible target for optimizing therapy in OHS patients.
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Affiliation(s)
- Szabolcs Baglyas
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, 1082 Üllői út 78/B, Budapest, Hungary.
| | - Luca Valkó
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, 1082 Üllői út 78/B, Budapest, Hungary
| | - Vivien Móró
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, 1082 Üllői út 78/B, Budapest, Hungary
| | - Eszter Podmaniczky
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, 1082 Üllői út 78/B, Budapest, Hungary
| | - Dorottya Czövek
- Department of Pediatrics, Semmelweis University, Budapest, Hungary
| | - Gergely Makan
- Department of Technical Informatics, University of Szeged, Szeged, Hungary
| | - Zoltán Gingl
- Department of Technical Informatics, University of Szeged, Szeged, Hungary
| | - János Gál
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, 1082 Üllői út 78/B, Budapest, Hungary
| | - Zoltán Hantos
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, 1082 Üllői út 78/B, Budapest, Hungary
| | - András Lorx
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, 1082 Üllői út 78/B, Budapest, Hungary
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Moya EA, Mesarwi OA. How far would you go to sleep better at high altitude? Sleep 2023; 46:6839988. [PMID: 36413093 PMCID: PMC9905773 DOI: 10.1093/sleep/zsac277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Indexed: 11/23/2022] Open
Affiliation(s)
- Esteban A Moya
- Section of Physiology, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California San Diego, La Jolla, CA, USA
| | - Omar A Mesarwi
- Section of Physiology, Division of Pulmonary, Critical Care, and Sleep Medicine, Department of Medicine, University of California San Diego, La Jolla, CA, USA
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Gharib A. Effect of continuous positive airway pressure on the respiratory system: a comprehensive review. THE EGYPTIAN JOURNAL OF BRONCHOLOGY 2023. [DOI: 10.1186/s43168-022-00175-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
Abstract
Background
CPAP is characterized by the application of a constant and continuous positive pressure into the patient’s airway. By delivering a constant pressure during both inspiration and expiration, CPAP increases functional residual capacity and opens collapsed or under ventilated alveoli, thus decreasing right to left intrapulmonary shunt and improving oxygenation in obese individuals.
Main body of abstract
Obesity is characterized by several alterations in the mechanics of the respiratory system that tend to further exaggerate impairment of gas exchange rendering these patients prone to perioperative complications, such as hypoxemia, hypercapnia, and atelectasis. Interestingly, CPAP has been advocated as an efficacious modality for prevention and treatment of postoperative atelectasis considered to be the most common postoperative respiratory complication. In OSA, the CPAP device works to splint the airway open and prevent the collapse of the upper airway that is the cardinal event of OSA leading improvement of sleep, quality of life and the reduction of the risks of the cardiovascular and neurocognitive side effects associated with the disease. Besides such a beneficial effect, there are other physiological benefits to CPAP: greater end-expiratory lung volume and consequent increase in oxygen stores, increased tracheal traction to improve upper airway patency and decrease in cardiac after load.
Conclusion
Due to various physiological benefits on the respiratory system CPAP therapy is crucial for the prevention postoperative complications particularly related to obesity and the cornerstone for the treatment of moderate to severe obstructive sleep apnea.
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Masa JF, Benítez ID, Sánchez-Quiroga MÁ, Gomez de Terreros FJ, Corral J, Romero A, Caballero-Eraso C, Ordax-Carbajo E, Troncoso MF, González M, López-Martín S, Marin JM, Martí S, Díaz-Cambriles T, Chiner E, Egea C, Barca J, Vázquez-Polo FJ, Negrín MA, Martel-Escobar M, Barbé F, Mokhlesi B. Effectiveness of CPAP vs. Noninvasive Ventilation Based on Disease Severity in Obesity Hypoventilation Syndrome and Concomitant Severe Obstructive Sleep Apnea. Arch Bronconeumol 2022; 58:228-236. [PMID: 35312607 DOI: 10.1016/j.arbres.2021.05.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 05/25/2021] [Accepted: 05/25/2021] [Indexed: 11/24/2022]
Abstract
RATIONALE Obesity hypoventilation syndrome (OHS) with concomitant severe obstructive sleep apnea (OSA) is treated with CPAP or noninvasive ventilation (NIV) during sleep. NIV is costlier, but may be advantageous because it provides ventilatory support. However, there are no long-term trials comparing these treatment modalities based on OHS severity. OBJECTIVE To determine if CPAP have similar effectiveness when compared to NIV according to OHS severity subgroups. METHODS Post hoc analysis of the Pickwick randomized clinical trial in which 215 ambulatory patients with untreated OHS and concomitant severe OSA, defined as apnoea-hypopnea index (AHI)≥30events/h, were allocated to NIV or CPAP. In the present analysis, the Pickwick cohort was divided in severity subgroups based on the degree of baseline daytime hypercapnia (PaCO2 of 45-49.9 or ≥50mmHg). Repeated measures of PaCO2 and PaO2 during the subsequent 3 years were compared between CPAP and NIV in the two severity subgroups. Statistical analysis was performed using linear mixed-effects model. RESULTS 204 patients, 97 in the NIV group and 107 in the CPAP group were analyzed. The longitudinal improvements of PaCO2 and PaO2 were similar between CPAP and NIV based on the PaCO2 severity subgroups. CONCLUSION In ambulatory patients with OHS and concomitant severe OSA who were treated with NIV or CPAP, long-term NIV therapy was similar to CPAP in improving awake hypercapnia, regardless of the severity of baseline hypercapnia. Therefore, in this patient population, the decision to prescribe CPAP or NIV cannot be solely based on the presenting level of PaCO2.
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Affiliation(s)
- Juan F Masa
- Respiratory Department, San Pedro de Alcántara Hospital, Cáceres, Spain; CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain; Instituto Universitario de Investigación Biosanitaria de Extremadura (INUBE), Spain.
| | - Iván D Benítez
- Institut de Recerca Biomédica de LLeida (IRBLLEIDA), Lleida, Spain; CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain
| | - Maria Á Sánchez-Quiroga
- Respiratory Department, Virgen del Puerto Hospital, Plasencia, Cáceres, Spain; CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain; Instituto Universitario de Investigación Biosanitaria de Extremadura (INUBE), Spain
| | - Francisco J Gomez de Terreros
- Respiratory Department, San Pedro de Alcántara Hospital, Cáceres, Spain; CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain; Instituto Universitario de Investigación Biosanitaria de Extremadura (INUBE), Spain
| | - Jaime Corral
- Respiratory Department, San Pedro de Alcántara Hospital, Cáceres, Spain; CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain; Instituto Universitario de Investigación Biosanitaria de Extremadura (INUBE), Spain
| | - Auxiliadora Romero
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío, Sevilla, Spain; CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain
| | - Candela Caballero-Eraso
- Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío, Sevilla, Spain; CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain
| | - Estrella Ordax-Carbajo
- Respiratory Department, University Hospital, Burgos, Spain; CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain
| | - Maria F Troncoso
- Respiratory Department, IIS Fundación Jiménez Díaz, Madrid, Spain; CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain
| | - Mónica González
- Respiratory Department, Valdecilla Hospital, Santander, Spain
| | | | - José M Marin
- Respiratory Department, Miguel Servet Hospital, Zaragoza, Spain; CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain
| | - Sergi Martí
- Respiratory Department, Vall d'Hebron Hospital, Barcelona, Spain; CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain
| | - Trinidad Díaz-Cambriles
- Respiratory Department, Doce de Octubre Hospital, Madrid, Spain; CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain
| | - Eusebi Chiner
- Respiratory Department, San Juan Hospital, Alicante, Spain
| | - Carlos Egea
- Respiratory Department, Alava University Hospital IRB, Vitoria, Spain; CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain
| | - Javier Barca
- Nursing Department, Extremadura University, Cáceres, Spain; Instituto Universitario de Investigación Biosanitaria de Extremadura (INUBE), Spain
| | | | - Miguel A Negrín
- Department of Quantitative Methods, Las Palmas de Gran Canaria University Canary Islands, Spain
| | - María Martel-Escobar
- Department of Quantitative Methods, Las Palmas de Gran Canaria University Canary Islands, Spain
| | - Ferrán Barbé
- Institut de Recerca Biomédica de LLeida (IRBLLEIDA), Lleida, Spain; CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain
| | - Babak Mokhlesi
- Medicine/Pulmonary and Critical Care, University of Chicago, IL, USA
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Lastra AC, Masa JF, Mokhlesi B. CPAP titration failure is not equivalent to long-term CPAP treatment failure in patients with obesity hypoventilation syndrome: a case series. J Clin Sleep Med 2021; 16:1975-1981. [PMID: 32713421 DOI: 10.5664/jcsm.8712] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
STUDY OBJECTIVES Medium and long-term trials comparing continuous positive airway pressure (CPAP) with noninvasive ventilation in patients with obesity hypoventilation syndrome have shown no differences in outcomes. However, it remains unclear whether CPAP therapy should be prescribed if significant hypoxemia persists during CPAP titration, despite optimization of upper airway obstructive events or if maximum CPAP pressure is reached. We aimed to examine the effects of 6 weeks of home CPAP therapy on gas exchange in patients with obesity hypoventilation syndrome who failed CPAP titration due to persistent hypoxemia. METHODS This case series is a substudy of a randomized-controlled trial evaluating efficacy of 3 different PAP modalities in obesity hypoventilation syndrome. Patients randomized to CPAP who failed titration and were prescribed CPAP are included. CPAP failure was defined as spending more than 20% of total sleep time with oxygen saturation below 90% despite adequate resolution of apneas and hypopneas. Follow-up data included in-laboratory polysomnogram on prescribed CPAP after 6 weeks of home CPAP therapy. RESULTS Three of seven participants (43%) randomized to CPAP failed CPAP titration. All were morbidly obese, had severe OSA (apnea-hypopnea index > 90 events/h) and severe sleep hypoxemia (percentage of total sleep time with oxygen saturation < 90% [T90] = 60-89%). Hypoxemia (T90: 43-67%, T80: 0-31%, and T70: 0-11%) and hypercapnia (transcutaneous pressure of CO₂ levels > 50 mm Hg) persisted during CPAP titration polysomnogram. The final polysomnogram after 6 weeks of adherent home CPAP therapy showed effective control of obstructive sleep apnea. Hypoventilation and hypoxemia severity decreased significantly in all 3 participants. CONCLUSIONS Our data suggest that CPAP titration failure does not equal CPAP treatment failure. CLINICAL TRIAL REGISTRATION Registry: ClinicalTrials.gov; Name: AVAPS-AE Efficacy Study; URL: https://clinicaltrials.gov/ct2/show/NCT01368614; Identifier: NCT01368614.
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Affiliation(s)
- Alejandra C Lastra
- Division of Pulmonary, Critical Care and Sleep Medicine, Rush University Medical Center, Chicago, Illinois
| | - Juan F Masa
- Respiratory Department, San Pedro de Alcántara Hospital, Cáceres, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Babak Mokhlesi
- Section of Pulmonary and Critical Care, Department of Medicine, University of Chicago, Chicago, Illinois
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Almeneessier AS, Aleissi S, Olaish AH, BaHammam AS. Long-Term Adherence to Positive Airway Pressure Therapy in Saudi Ambulatory Patients with Obesity Hypoventilation Syndrome and Severe Obstructive Sleep Apnea: A One-Year Follow-Up Prospective Observational Study. Nat Sci Sleep 2021; 13:63-74. [PMID: 33469401 PMCID: PMC7813470 DOI: 10.2147/nss.s290349] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 12/22/2020] [Indexed: 12/14/2022] Open
Abstract
PURPOSE Long-term studies assessing positive airway pressure (PAP) therapy adherence in patients with obesity hypoventilation (OHS) are limited. The aim of this study was to assess PAP therapy adherence in Arab (Saudi) patients with OHS and an apnea-hypopnea index (AHI) >30/h. METHODS A prospective cohort study of consecutive adult patients diagnosed with OHS between March 2010 and September 2019 was conducted. During the therapeutic sleep study, all OHS patients were started on continuous PAP (CPAP). Patients who failed to maintain oxygen saturation ≥88% despite the elimination of obstructive respiratory events were shifted to bi-level PAP (BPAP). Objective assessment of adherence was performed at 1, 6, and 12 months after initiating PAP therapy. We adopted the American-Thoracic-Society criteria for PAP adherence. RESULTS The study included 101 patients (women = 65 patients) with OHS, an AHI ≥30/h, and a mean age of 54.9 ± 12.7 years. Successful titration on CPAP was achieved in 64.4% of the patients and BPAP was required for 35.6% of the patients who failed CPAP titration. At the end of the study, 43.6% of the patients used PAP therapy in an acceptable manner. Adherence after 1 and 6 months was the only independent predictors of adherence at 12 months. CONCLUSION PAP adherence among Saudi patients with OHS and severe obstructive sleep apnea was relatively low. Almost two-thirds of patients tolerated CPAP titration with the elimination of respiratory events and desaturation. Early adherence to PAP therapy was the only predictor of PAP therapy adherence at the end of the study.
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Affiliation(s)
- Aljohara S Almeneessier
- The University Sleep Disorders Center, Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia.,Department of Family and Community Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Salih Aleissi
- The University Sleep Disorders Center, Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Awad H Olaish
- The University Sleep Disorders Center, Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ahmed S BaHammam
- The University Sleep Disorders Center, Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Freire C, Pho H, Kim LJ, Wang X, Dyavanapalli J, Streeter SR, Fleury-Curado T, Sennes LU, Mendelowitz D, Polotsky VY. Intranasal Leptin Prevents Opioid-induced Sleep-disordered Breathing in Obese Mice. Am J Respir Cell Mol Biol 2020; 63:502-509. [PMID: 32603263 DOI: 10.1165/rcmb.2020-0117oc] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Respiratory depression is the main cause of morbidity and mortality associated with opioids. Obesity increases opioid-related mortality, which is mostly related to comorbid obstructive sleep apnea. Naloxone, a μ-opioid receptor blocker, is an effective antidote, but it reverses analgesia. Like humans with obesity, mice with diet-induced obesity hypoventilate during sleep and develop obstructive sleep apnea, which can be treated with intranasal leptin. We hypothesized that intranasal leptin reverses opioid-induced sleep-disordered breathing in obese mice without decreasing analgesia. To test this hypothesis, mice with diet-induced obesity were treated with morphine at 10 mg/kg subcutaneously and with leptin or placebo intranasally. Sleep and breathing were recorded by barometric plethysmography, and pain sensitivity was measured by the tail-flick test. Excitatory postsynaptic currents were recorded in vitro from hypoglossal motor neurons after the application of the μ-opioid receptor agonist [D-Ala2, N-MePhe4, Gly-ol]-enkephalin and leptin. Morphine dramatically increased the frequency of apneas and greatly increased the severity of hypoventilation and obstructive sleep apnea. Leptin decreased the frequency of apneas, improved obstructive sleep apnea, and completely reversed hypoventilation, whereas morphine analgesia was enhanced. Our in vitro studies demonstrated that [D-Ala2, N-MePhe4, Gly-ol]-enkephalin reduced the frequency of excitatory postsynaptic currents in hypoglossal motoneurons and that application of leptin restored excitatory synaptic neurotransmission. Our findings suggest that intranasal leptin may prevent opioid respiratory depression during sleep in patients with obesity receiving opioids without reducing analgesia.
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Affiliation(s)
- Carla Freire
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Otolaryngology, University of São Paulo, São Paulo, Brazil; and
| | - Huy Pho
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Lenise J Kim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Xin Wang
- Department of Pharmacology and Physiology, The George Washington University, Washington, DC
| | - Jhansi Dyavanapalli
- Department of Pharmacology and Physiology, The George Washington University, Washington, DC
| | - Stone R Streeter
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Thomaz Fleury-Curado
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland.,Department of Otolaryngology, University of São Paulo, São Paulo, Brazil; and
| | - Luiz U Sennes
- Department of Otolaryngology, University of São Paulo, São Paulo, Brazil; and
| | - David Mendelowitz
- Department of Pharmacology and Physiology, The George Washington University, Washington, DC
| | - Vsevolod Y Polotsky
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Gudivada SD, Rajasurya V, Spector AR. Qualifying Patients for Noninvasive Positive Pressure Ventilation Devices on Hospital Discharge. Chest 2020; 158:2524-2531. [PMID: 32798519 DOI: 10.1016/j.chest.2020.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 08/01/2020] [Accepted: 08/05/2020] [Indexed: 11/30/2022] Open
Abstract
When and how do I qualify inpatients with acute on chronic hypercapnic respiratory failure for home noninvasive positive-pressure ventilation at the time of discharge? A 44-year-old woman with morbid obesity (BMI, 48) was brought to the hospital by her boyfriend for 1 day of confusion and reduced alertness. She had a history of chronic dyspnea on exertion and 10-pack-years of smoking. She also had history of well-treated diabetes and hypertension. In the ER, she was found to be somnolent but arousable and following commands appropriately. Her oxygen saturation was 86% on room air, and arterial blood gases indicated a pH of 7.16 with a Paco2 of 87 mm Hg, a Pao2 of 60 mm Hg, and a bicarbonate of 42 mEq/L. Chest radiograph showed mild pulmonary vascular congestion. She was started on continuous bilevel positive airway pressure and medical therapy, with clinical improvement.
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Affiliation(s)
| | - Venkat Rajasurya
- Department of Pulmonary Critical Care Medicine, Novant Forsyth Medical Center, Winston-Salem, NC
| | - Andrew R Spector
- Sleep Medicine, Department of Neurology, Duke University School of Medicine, Durham, NC
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Ramírez Molina VR, Masa Jiménez JF, Gómez de Terreros Caro FJ, Corral Peñafiel J. Effectiveness of different treatments in obesity hypoventilation syndrome. Pulmonology 2020; 26:370-377. [PMID: 32553827 DOI: 10.1016/j.pulmoe.2020.05.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Accepted: 05/15/2020] [Indexed: 12/23/2022] Open
Abstract
Obesity hypoventilation syndrome (OHS) is an undesirable consequence of obesity, defined as daytime hypoventilation, sleep disorder breathing and obesity; during the past few years the prevalence of extreme obesity has markedly increased worldwide consequently increasing the prevalence of OHS. Patients with OHS have a lower quality of life and a higher risk of unfavourable cardiometabolic consequences. Early diagnosis and effective treatment can lead to significant improvement in patient outcomes; therefore, such data has noticeably raised interest in the management and treatment of this sleep disorder. This paper will discuss the findings on the main current treatment modalities OHS will be discussed.
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Affiliation(s)
- V R Ramírez Molina
- Pulmonary and Sleep Medicine, Regional General Hospital N.2 of the Mexican Social Security Institute (IMSS), Querétaro, Mexico
| | - J F Masa Jiménez
- Division of Pulmonary Medicine, San Pedro de Alcántara Hospital, Cáceres, Spain; CIBER of Respiratory Diseases (CIBERES), Madrid, Spain.
| | | | - J Corral Peñafiel
- Division of Pulmonary Medicine, San Pedro de Alcántara Hospital, Cáceres, Spain
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Masa JF, Mokhlesi B, Benítez I, Mogollon MV, Gomez de Terreros FJ, Sánchez-Quiroga MÁ, Romero A, Caballero-Eraso C, Alonso-Álvarez ML, Ordax-Carbajo E, Gomez-Garcia T, González M, López-Martín S, Marin JM, Martí S, Díaz-Cambriles T, Chiner E, Egea C, Barca J, Vázquez-Polo FJ, Negrín MA, Martel-Escobar M, Barbe F, Corral J. Echocardiographic Changes with Positive Airway Pressure Therapy in Obesity Hypoventilation Syndrome. Long-Term Pickwick Randomized Controlled Clinical Trial. Am J Respir Crit Care Med 2020; 201:586-597. [PMID: 31682462 DOI: 10.1164/rccm.201906-1122oc] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Rationale: Obesity hypoventilation syndrome (OHS) has been associated with cardiac dysfunction. However, randomized trials assessing the impact of long-term noninvasive ventilation (NIV) or continuous positive airway pressure (CPAP) on cardiac structure and function assessed by echocardiography are lacking.Objectives: In a prespecified secondary analysis of the largest multicenter randomized controlled trial of OHS (Pickwick Project; N = 221 patients with OHS and coexistent severe obstructive sleep apnea), we compared the effectiveness of three years of NIV and CPAP on structural and functional echocardiographic changes.Methods: At baseline and annually during three sequential years, patients underwent transthoracic two-dimensional and Doppler echocardiography. Echocardiographers at each site were blinded to the treatment allocation. Statistical analysis was performed using a linear mixed-effects model with a treatment group and repeated measures interaction to determine the differential effect between CPAP and NIV.Measurements and Main Results: A total of 196 patients were analyzed: 102 were treated with CPAP and 94 were treated with NIV. Systolic pulmonary artery pressure decreased from 40.5 ± 1.47 mm Hg at baseline to 35.3 ± 1.33 mm Hg at three years with CPAP, and from 41.5 ± 1.56 mm Hg to 35.5 ± 1.42 with NIV (P < 0.0001 for longitudinal intragroup changes for both treatment arms). However, there were no significant differences between groups. NIV and CPAP therapies similarly improved left ventricular diastolic dysfunction and reduced left atrial diameter. Both NIV and CPAP improved respiratory function and dyspnea.Conclusions: In patients with OHS who have concomitant severe obstructive sleep apnea, long-term treatment with NIV and CPAP led to similar degrees of improvement in pulmonary hypertension and left ventricular diastolic dysfunction.Clinical trial registered with www.clinicaltrials.gov (NCT01405976).
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Affiliation(s)
- Juan F Masa
- Respiratory Department, San Pedro de Alcántara Hospital, Cáceres, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain.,Instituto Universitario de Investigación Biosanitaria de Extremadura (INUBE), Badajoz, Spain
| | - Babak Mokhlesi
- Medicine/Pulmonary and Critical Care, University of Chicago, Chicago, Illinois
| | - Iván Benítez
- CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain.,Institut de Recerca Biomédica de Lleida (IRBLLEIDA), Lleida, Spain
| | | | - Francisco Javier Gomez de Terreros
- Respiratory Department, San Pedro de Alcántara Hospital, Cáceres, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain.,Instituto Universitario de Investigación Biosanitaria de Extremadura (INUBE), Badajoz, Spain
| | - Maria Ángeles Sánchez-Quiroga
- CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain.,Instituto Universitario de Investigación Biosanitaria de Extremadura (INUBE), Badajoz, Spain.,Respiratory Department, Virgen del Puerto Hospital, Plasencia, Cáceres, Spain
| | - Auxiliadora Romero
- CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain.,Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Sevilla, Spain
| | - Candela Caballero-Eraso
- CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain.,Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Sevilla, Spain
| | - Maria Luz Alonso-Álvarez
- CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain.,Respiratory Department, University Hospital, Burgos, Spain
| | - Estrella Ordax-Carbajo
- CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain.,Respiratory Department, University Hospital, Burgos, Spain
| | - Teresa Gomez-Garcia
- CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain.,Respiratory Department, IIS Fundación Jiménez Díaz, Madrid, Spain
| | - Mónica González
- Respiratory Department, Valdecilla Hospital, Santander, Spain
| | | | - José M Marin
- CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain.,Respiratory Department, Miguel Servet Hospital, Zaragoza, Spain
| | - Sergi Martí
- CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain.,Respiratory Department, Valld'Hebron Hospital, Barcelona, Spain
| | - Trinidad Díaz-Cambriles
- CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain.,Respiratory Department, Doce de Octubre Hospital, Madrid, Spain
| | - Eusebi Chiner
- Respiratory Department, San Juan Hospital, Alicante, Spain
| | - Carlos Egea
- CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain.,Respiratory Department, Alava University Hospital IRB, Vitoria, Spain
| | - Javier Barca
- Instituto Universitario de Investigación Biosanitaria de Extremadura (INUBE), Badajoz, Spain.,Nursing Department, Extremadura University, Cáceres, Spain; and
| | | | - Miguel A Negrín
- Department of Quantitative Methods, University of Las Palmas de Gran Canaria, Las Palmas, Spain
| | - María Martel-Escobar
- Department of Quantitative Methods, University of Las Palmas de Gran Canaria, Las Palmas, Spain
| | - Ferran Barbe
- CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain.,Institut de Recerca Biomédica de Lleida (IRBLLEIDA), Lleida, Spain
| | - Jaime Corral
- Respiratory Department, San Pedro de Alcántara Hospital, Cáceres, Spain.,CIBER de Enfermedades Respiratorias (CIBERES), Madrid, Spain.,Instituto Universitario de Investigación Biosanitaria de Extremadura (INUBE), Badajoz, Spain
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14
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Masa JF, Benítez I, Sánchez-Quiroga MÁ, Gomez de Terreros FJ, Corral J, Romero A, Caballero-Eraso C, Alonso-Álvarez ML, Ordax-Carbajo E, Gomez-Garcia T, González M, López-Martín S, Marin JM, Martí S, Díaz-Cambriles T, Chiner E, Egea C, Barca J, Vázquez-Polo FJ, Negrín MA, Martel-Escobar M, Barbé F, Mokhlesi B. Long-term Noninvasive Ventilation in Obesity Hypoventilation Syndrome Without Severe OSA: The Pickwick Randomized Controlled Trial. Chest 2020; 158:1176-1186. [PMID: 32343963 DOI: 10.1016/j.chest.2020.03.068] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Revised: 02/27/2020] [Accepted: 03/19/2020] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Noninvasive ventilation (NIV) is an effective form of treatment in obesity hypoventilation syndrome (OHS) with severe OSA. However, there is paucity of evidence in patients with OHS without severe OSA phenotype. RESEARCH QUESTION Is NIV effective in OHS without severe OSA phenotype? STUDY DESIGN AND METHODS In this multicenter, open-label parallel group clinical trial performed at 16 sites in Spain, we randomly assigned 98 stable ambulatory patients with untreated OHS and apnea-hypopnea index < 30 events/h (ie, no severe OSA) to NIV or lifestyle modification (control group) using simple randomization through an electronic database. The primary end point was hospitalization days per year. Secondary end points included other hospital resource utilization, incident cardiovascular events, mortality, respiratory functional tests, BP, quality of life, sleepiness, and other clinical symptoms. Both investigators and patients were aware of the treatment allocation; however, treating physicians from the routine care team were not aware of patients' enrollment in the clinical trial. The study was stopped early in its eighth year because of difficulty identifying patients with OHS without severe OSA. The analysis was performed according to intention-to-treat and per-protocol principles and by adherence subgroups. RESULTS Forty-nine patients in the NIV group and 49 in the control group were randomized, and 48 patients in each group were analyzed. During a median follow-up of 4.98 years (interquartile range, 2.98-6.62), the mean hospitalization days per year ± SD was 2.60 ± 5.31 in the control group and 2.71 ± 4.52 in the NIV group (adjusted rate ratio, 1.07; 95% CI, 0.44-2.59; P = .882). NIV therapy, in contrast with the control group, produced significant longitudinal improvement in Paco2, pH, bicarbonate, quality of life (Medical Outcome Survey Short Form 36 physical component), and daytime sleepiness. Moreover, per-protocol analysis showed a statistically significant difference for the time until the first ED visit favoring NIV. In the subgroup with high NIV adherence, the time until the first event of hospital admission, ED visit, and mortality was longer than in the low adherence subgroup. Adverse events were similar between arms. INTERPRETATION In stable ambulatory patients with OHS without severe OSA, NIV and lifestyle modification had similar long-term hospitalization days per year. A more intensive program aimed at improving NIV adherence may lead to better outcomes. Larger studies are necessary to better determine the long-term benefit of NIV in this subgroup of OHS. TRIAL REGISTRY ClinicalTrials.gov; No.: NCT01405976; URL: www.clinicaltrials.gov.
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Affiliation(s)
- Juan F Masa
- Respiratory Department, San Pedro de Alcántara Hospital, Cáceres, Spain; CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain; Instituto Universitario de Investigación Biosanitaria de Extremadura (INUBE), Badajoz, Spain.
| | - Iván Benítez
- CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain; Institut de Recerca Biomédica de LLeida (IRBLLEIDA), Lleida, Spain
| | - Maria Á Sánchez-Quiroga
- CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain; Instituto Universitario de Investigación Biosanitaria de Extremadura (INUBE), Badajoz, Spain; Respiratory Department, Virgen del Puerto Hospital, Plasencia, Cáceres, Spain
| | - Francisco J Gomez de Terreros
- Respiratory Department, San Pedro de Alcántara Hospital, Cáceres, Spain; CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain; Instituto Universitario de Investigación Biosanitaria de Extremadura (INUBE), Badajoz, Spain
| | - Jaime Corral
- Respiratory Department, San Pedro de Alcántara Hospital, Cáceres, Spain; CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain; Instituto Universitario de Investigación Biosanitaria de Extremadura (INUBE), Badajoz, Spain
| | - Auxiliadora Romero
- CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain; Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Candela Caballero-Eraso
- CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain; Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío, Sevilla, Spain
| | - Maria L Alonso-Álvarez
- CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain; Respiratory Department, University Hospital, Burgos, Spain
| | - Estrella Ordax-Carbajo
- CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain; Respiratory Department, University Hospital, Burgos, Spain
| | - Teresa Gomez-Garcia
- CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain; Respiratory Department, IIS Fundación Jiménez Díaz, Madrid, Spain
| | - Mónica González
- Respiratory Department, Valdecilla Hospital, Santander, Spain
| | | | - José M Marin
- CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain; Respiratory Department, Miguel Servet Hospital, Zaragoza, Spain
| | - Sergi Martí
- CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain; Respiratory Department, Vall d'Hebron Hospital, Barcelona, Spain
| | - Trinidad Díaz-Cambriles
- CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain; Respiratory Department, Doce de Octubre Hospital, Madrid, Spain
| | - Eusebi Chiner
- Respiratory Department, San Juan Hospital, Alicante, Spain
| | - Carlos Egea
- CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain; Respiratory Department, Alava University Hospital IRB, Vitoria, Spain
| | - Javier Barca
- Instituto Universitario de Investigación Biosanitaria de Extremadura (INUBE), Badajoz, Spain; Nursing Department, Extremadura University, Cáceres, Spain
| | - Francisco J Vázquez-Polo
- Department of Quantitative Methods, Las Palmas de Gran Canaria University, Canary Islands, Spain
| | - Miguel A Negrín
- Department of Quantitative Methods, Las Palmas de Gran Canaria University, Canary Islands, Spain
| | - María Martel-Escobar
- Department of Quantitative Methods, Las Palmas de Gran Canaria University, Canary Islands, Spain
| | - Ferrán Barbé
- CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain; Institut de Recerca Biomédica de LLeida (IRBLLEIDA), Lleida, Spain
| | - Babak Mokhlesi
- Department of Medicine/Pulmonary and Critical Care, University of Chicago, IL
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15
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Masa JF, Mokhlesi B, Benítez I, Gómez de Terreros Caro FJ, Sánchez-Quiroga MÁ, Romero A, Caballero C, Alonso-Álvarez ML, Ordax-Carbajo E, Gómez-García T, González M, López-Martín S, Marin JM, Martí S, Díaz-Cambriles T, Chiner E, Egea C, Barca J, Vázquez-Polo FJ, Negrín MA, Martel-Escobar M, Barbé F, Corral-Peñafiel J. Cost-effectiveness of positive airway pressure modalities in obesity hypoventilation syndrome with severe obstructive sleep apnoea. Thorax 2020; 75:459-467. [PMID: 32217780 DOI: 10.1136/thoraxjnl-2019-213622] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 10/16/2019] [Accepted: 11/25/2019] [Indexed: 11/03/2022]
Abstract
BACKGROUND Obesity hypoventilation syndrome (OHS) is treated with either non-invasive ventilation (NIV) or CPAP, but there are no long-term cost-effectiveness studies comparing the two treatment modalities. OBJECTIVES We performed a large, multicentre, randomised, open-label controlled study to determine the comparative long-term cost and effectiveness of NIV versus CPAP in patients with OHS with severe obstructive sleep apnoea (OSA) using hospitalisation days as the primary outcome measure. METHODS Hospital resource utilisation and within trial costs were evaluated against the difference in effectiveness based on the primary outcome (hospitalisation days/year, transformed and non-transformed in monetary term). Costs and effectiveness were estimated from a log-normal distribution using a Bayesian approach. A secondary analysis by adherence subgroups was performed. RESULTS In total, 363 patients were selected, 215 were randomised and 202 were available for the analysis. The median (IQR) follow-up was 3.01 (2.91-3.14) years for NIV group and 3.00 (2.92-3.17) years for CPAP. The mean (SD) Bayesian estimated hospital days was 2.13 (0.73) for CPAP and 1.89 (0.78) for NIV. The mean (SD) Bayesian estimated cost per patient/year in the NIV arm, excluding hospitalisation costs, was €2075.98 (91.6), which was higher than the cost in the CPAP arm of €1219.06 (52.3); mean difference €857.6 (105.5). CPAP was more cost-effective than NIV (99.5% probability) because longer hospital stay in the CPAP arm was compensated for by its lower costs. Similar findings were observed in the high and low adherence subgroups. CONCLUSION CPAP is more cost-effective than NIV; therefore, CPAP should be the preferred treatment for patients with OHS with severe OSA. TRIAL REGISTRATION NUMBER NCT01405976.
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Affiliation(s)
- Juan F Masa
- Respiratory Department, San Pedro de Alcantara Hospital, Caceres, Spain .,CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain.,Institut de Recerca Biomédica de LLeida (IRBLLEIDA), Lleida, Spain
| | - Babak Mokhlesi
- Instituto Universitario deInvestigación Biosanitaria de Extremadura (INUBE), Romero, Auxiliadora
| | - Iván Benítez
- CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain.,Medicine/Pulmonary and Critical Care, University of Chicago, Chicago, Illinois, USA
| | - Francisco Javier Gómez de Terreros Caro
- Respiratory Department, San Pedro de Alcantara Hospital, Caceres, Spain.,CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain.,Institut de Recerca Biomédica de LLeida (IRBLLEIDA), Lleida, Spain
| | - M-Ángeles Sánchez-Quiroga
- CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain.,Institut de Recerca Biomédica de LLeida (IRBLLEIDA), Lleida, Spain.,Respiratory Department, Virgen del Rocio University Hospital, Plasencia, Spain
| | - Auxiliadora Romero
- CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain.,Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Sevilla, Spain
| | - Candela Caballero
- CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain.,Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Sevilla, Spain
| | - Maria Luz Alonso-Álvarez
- CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain.,Respiratory Department, Universitario de Burgos Hospital, Burgos, Spain
| | - Estrella Ordax-Carbajo
- CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain.,Respiratory Department, Universitario de Burgos Hospital, Burgos, Spain
| | - Teresa Gómez-García
- CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain.,Pulmonology, IIS Fundación Jiménez Díaz, Madrid, Spain
| | - Mónica González
- Respiratory Department, Valdecilla Hospital, Santander, Spain
| | | | - Jose M Marin
- CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain.,Respiratory Department, Miguel Servet Hospital, Zaragoza, Spain
| | - Sergi Martí
- CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain.,Respiratory Department, Valld'Hebron Hospital, Barcelona, Spain
| | - Trinidad Díaz-Cambriles
- CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain.,Respiratory Department, Doce de Octubre Hospital, Madrid, Spain
| | - Eusebi Chiner
- Respiratory Department, San Juan Hospital, Alicante, Spain
| | - Carlos Egea
- Respiratory Department, Gregorio Marañon Hospital, Madrid, Spain.,Respiratory Department, La Paz Hospital, Madrid, Spain
| | - Javier Barca
- Institut de Recerca Biomédica de LLeida (IRBLLEIDA), Lleida, Spain.,Nursing Department, Extremadura University, Cáceres, Spain
| | | | - Miguel Angel Negrín
- Department of Quantitative Methods, University of Las Palmas de Gran Canaria, Las Palmas, Spain
| | - María Martel-Escobar
- Department of Quantitative Methods, University of Las Palmas de Gran Canaria, Las Palmas, Spain
| | - Ferran Barbé
- CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain.,Medicine/Pulmonary and Critical Care, University of Chicago, Chicago, Illinois, USA
| | - Jaime Corral-Peñafiel
- Respiratory Department, San Pedro de Alcantara Hospital, Caceres, Spain.,CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain.,Institut de Recerca Biomédica de LLeida (IRBLLEIDA), Lleida, Spain
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Balnis J, Korponay TC, Jaitovich A. AMP-Activated Protein Kinase (AMPK) at the Crossroads Between CO 2 Retention and Skeletal Muscle Dysfunction in Chronic Obstructive Pulmonary Disease (COPD). Int J Mol Sci 2020; 21:E955. [PMID: 32023946 PMCID: PMC7037951 DOI: 10.3390/ijms21030955] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 01/22/2020] [Accepted: 01/28/2020] [Indexed: 12/17/2022] Open
Abstract
Skeletal muscle dysfunction is a major comorbidity in chronic obstructive pulmonary disease (COPD) and other pulmonary conditions. Chronic CO2 retention, or hypercapnia, also occur in some of these patients. Both muscle dysfunction and hypercapnia associate with higher mortality in these populations. Over the last years, we have established a mechanistic link between hypercapnia and skeletal muscle dysfunction, which is regulated by AMPK and causes depressed anabolism via reduced ribosomal biogenesis and accelerated catabolism via proteasomal degradation. In this review, we discuss the main findings linking AMPK with hypercapnic pulmonary disease both in the lungs and skeletal muscles, and also outline potential avenues for future research in the area based on knowledge gaps and opportunities to expand mechanistic research with translational implications.
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Affiliation(s)
- Joseph Balnis
- Division of Pulmonary and Critical Care Medicine, Albany Medical College, Albany, NY 12208, USA; (J.B.); (T.C.K.)
- Department of Molecular and Cellular Physiology, Albany Medical College, Albany, NY 12208, USA
| | - Tanner C. Korponay
- Division of Pulmonary and Critical Care Medicine, Albany Medical College, Albany, NY 12208, USA; (J.B.); (T.C.K.)
- Department of Molecular and Cellular Physiology, Albany Medical College, Albany, NY 12208, USA
| | - Ariel Jaitovich
- Division of Pulmonary and Critical Care Medicine, Albany Medical College, Albany, NY 12208, USA; (J.B.); (T.C.K.)
- Department of Molecular and Cellular Physiology, Albany Medical College, Albany, NY 12208, USA
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Arellano-Maric MP, Hamm C, Duiverman ML, Schwarz S, Callegari J, Storre JH, Schmoor C, Spielmanns M, Galetke W, Windisch W. Obesity hypoventilation syndrome treated with non-invasive ventilation: Is a switch to CPAP therapy feasible? Respirology 2019; 25:435-442. [PMID: 31597227 DOI: 10.1111/resp.13704] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 08/20/2019] [Accepted: 09/03/2019] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND OBJECTIVE Obesity hypoventilation syndrome (OHS) can be treated with either continuous positive airway pressure (CPAP) or non-invasive ventilation (NIV) therapy; the device choice has important economic and operational implications. METHODS This multicentre interventional trial investigated the safety and short-term efficacy of switching stable OHS patients who were on successful NIV therapy for ≥3 months to CPAP therapy. Patients underwent an autotitrating CPAP night under polysomnography (PSG); if the ensuing parameters were acceptable, they were sent home on a fixed CPAP for a 4-6-week period. It was hypothesized that blood gas analysis, PSG parameters and lung function tests would remain unchanged. RESULTS A total of 42 OHS patients were recruited, of whom 37 patients were switched to CPAP therapy. All patients had a history of severe obstructive sleep apnoea syndrome; chronic obstructive pulmonary disease (COPD) (Global Initiative for Obstructive Lung Disease (GOLD) I/II) was present in 52%. Regarding the primary outcome, 30 of 42 patients (71%, 95% CI: 55-84%) maintained daytime partial pressure of carbon dioxide (PaCO2 ) levels ≤45 mm Hg after the home CPAP period. There was no further impairment in quality of life, sleep parameters or lung function. Interestingly, 24 patients (65%) preferred CPAP as their long-term therapy, despite the high pressure levels used (mean: 13.8 ± 1.8 mbar). After the CPAP period, 7 of 37 patients were categorized as CPAP failure, albeit only due to mild hypercapnia (mean: 47.9 ± 2.7 mm Hg). CONCLUSION It is feasible to switch most stable OHS patients from NIV to CPAP therapy, a step that could significantly reduce health-related costs. The auto-adjusted CPAP device, used in combination with the analysis of the PSG and capnometry, is a valid titration method in OHS patients.
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Affiliation(s)
- Maria P Arellano-Maric
- Department of Pneumology, Cologne Merheim Hospital, Kliniken der Stadt Köln, Germany.,Department of Pneumology, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Christine Hamm
- Department of Pneumology, Cologne Merheim Hospital, Kliniken der Stadt Köln, Germany.,Faculty of Health/School of Medicine, Witten/Herdecke University, Cologne, Germany
| | - Marieke L Duiverman
- Department of Pulmonary Diseases/Home Mechanical Ventilation, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Groningen Research Institute of Asthma and COPD, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Sarah Schwarz
- Department of Pneumology, Cologne Merheim Hospital, Kliniken der Stadt Köln, Germany.,Faculty of Health/School of Medicine, Witten/Herdecke University, Cologne, Germany
| | - Jens Callegari
- Department of Pneumology, Cologne Merheim Hospital, Kliniken der Stadt Köln, Germany.,Faculty of Health/School of Medicine, Witten/Herdecke University, Cologne, Germany
| | - Jan H Storre
- Department of Intensive Care, Sleep Medicine and Mechanical Ventilation, Asklepios, Fachkliniken Munich-Gauting, Gauting, Germany.,Department of Pneumology, University Medical Center Freiburg, Freiburg, Germany
| | - Claudia Schmoor
- Clinical Trials Center, University Medical Center, Freiburg, Germany
| | - Marc Spielmanns
- Faculty of Health/School of Medicine, Witten/Herdecke University, Cologne, Germany.,Department of Pneumology, St. Remigius Hospital, Opladen, Germany
| | - Wolfgang Galetke
- Department of Pneumology, Hospital der Augustinerinnen, Cologne, Germany
| | - Wolfram Windisch
- Department of Pneumology, Cologne Merheim Hospital, Kliniken der Stadt Köln, Germany.,Faculty of Health/School of Medicine, Witten/Herdecke University, Cologne, Germany
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Masa JF, Mokhlesi B, Benítez I, Gomez de Terreros FJ, Sánchez-Quiroga MÁ, Romero A, Caballero-Eraso C, Terán-Santos J, Alonso-Álvarez ML, Troncoso MF, González M, López-Martín S, Marin JM, Martí S, Díaz-Cambriles T, Chiner E, Egea C, Barca J, Vázquez-Polo FJ, Negrín MA, Martel-Escobar M, Barbe F, Corral J. Long-term clinical effectiveness of continuous positive airway pressure therapy versus non-invasive ventilation therapy in patients with obesity hypoventilation syndrome: a multicentre, open-label, randomised controlled trial. Lancet 2019; 393:1721-1732. [PMID: 30935737 DOI: 10.1016/s0140-6736(18)32978-7] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 10/29/2018] [Accepted: 11/06/2018] [Indexed: 12/14/2022]
Abstract
BACKGROUND Obesity hypoventilation syndrome is commonly treated with continuous positive airway pressure or non-invasive ventilation during sleep. Non-invasive ventilation is more complex and costly than continuous positive airway pressure but might be advantageous because it provides ventilatory support. To date there have been no long-term trials comparing these treatment modalities. We therefore aimed to determine the long-term comparative effectiveness of both treatment modalities. METHODS We did a multicentre, open-label, randomised controlled trial at 16 clinical sites in Spain. We included patients aged 15-80 years with untreated obesity hypoventilation syndrome and an apnoea-hypopnoea index of 30 or more events per h. We randomly assigned patients, using simple randomisation through an electronic database, to receive treatment with either non-invasive ventilation or continuous positive airway pressure. Both investigators and patients were aware of the treatment allocation. The research team was not involved in deciding hospital treatment, duration of treatment in the hospital, and adjustment of medications, as well as adjudicating cardiovascular events or cause of mortality. Treating clinicians from the routine care team were not aware of the treatment allocation. The primary outcome was the number of hospitalisation days per year. The analysis was done according to the intention-to-treat principle. This study is registered with ClinicalTrials.gov, number NCT01405976. FINDINGS From May 4, 2009, to March 25, 2013, 100 patients were randomly assigned to the non-invasive ventilation group and 115 to the continuous positive airway pressure group, of which 97 patients in the non-invasive ventilation group and 107 in the continuous positive airway pressure group were included in the analysis. The median follow-up was 5·44 years (IQR 4·45-6·37) for all patients, 5·37 years (4·36-6·32) in the continuous positive airway pressure group, and 5·55 years (4·53-6·50) in the non-invasive ventilation group. The mean hospitalisation days per patient-year were 1·63 (SD 3·74) in the continuous positive airway pressure group and 1·44 (3·07) in the non-invasive ventilation group (adjusted rate ratio 0·78, 95% CI 0·34-1·77; p=0·561). Adverse events were similar between both groups. INTERPRETATION In stable patients with obesity hypoventilation syndrome and severe obstructive sleep apnoea, non-invasive ventilation and continuous positive airway pressure have similar long-term effectiveness. Given that continuous positive airway pressure has lower complexity and cost, continuous positive airway pressure might be the preferred first-line positive airway pressure treatment modality until more studies become available. FUNDING Instituto de Salud Carlos III, Spanish Respiratory Foundation, and Air Liquide Spain.
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Affiliation(s)
- Juan F Masa
- Respiratory Department, San Pedro de Alcántara Hospital, Cáceres, Spain; CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain; Instituto Universitario de Investigación Biosanitaria de Extremadura (INUBE), Cáceres, Spain.
| | - Babak Mokhlesi
- Department of Medicine, University of Chicago, Chicago, IL, USA
| | - Iván Benítez
- Respiratory Department, Institut de Recerca Biomédica de LLeida (IRBLLEIDA), Lleida, Spain; CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain
| | - Francisco Javier Gomez de Terreros
- Respiratory Department, San Pedro de Alcántara Hospital, Cáceres, Spain; CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain; Instituto Universitario de Investigación Biosanitaria de Extremadura (INUBE), Cáceres, Spain
| | - Maria Ángeles Sánchez-Quiroga
- Respiratory Department, Virgen del Puerto Hospital, Plasencia, Cáceres, Spain; CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain; Instituto Universitario de Investigación Biosanitaria de Extremadura (INUBE), Cáceres, Spain
| | - Auxiliadora Romero
- CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain; Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Sevilla, Spain
| | - Candela Caballero-Eraso
- CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain; Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío, Universidad de Sevilla, Sevilla, Spain
| | - Joaquin Terán-Santos
- CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain; Respiratory Department, University Hospital, Burgos, Spain
| | - Maria Luz Alonso-Álvarez
- CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain; Respiratory Department, University Hospital, Burgos, Spain
| | - Maria F Troncoso
- CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain; Respiratory Department, IIS Fundación Jiménez Díaz, Madrid, Spain
| | - Mónica González
- Respiratory Department, Valdecilla Hospital, Santander, Spain
| | | | - José M Marin
- CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain; Respiratory Department, Miguel Servet Hospital, Zaragoza, Spain
| | - Sergi Martí
- CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain; Respiratory Department, Valld'Hebron Hospital, Barcelona, Spain
| | - Trinidad Díaz-Cambriles
- CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain; Respiratory Department, Doce de Octubre Hospital, Madrid, Spain
| | - Eusebi Chiner
- Respiratory Department, San Juan Hospital, Alicante, Spain
| | - Carlos Egea
- CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain; Respiratory Department, Alava University Hospital IRB, Vitoria, Spain
| | - Javier Barca
- Instituto Universitario de Investigación Biosanitaria de Extremadura (INUBE), Cáceres, Spain; Nursing Department, Extremadura University, Cáceres, Spain
| | | | - Miguel A Negrín
- Department of Quantitative Methods, Las Palmas de Gran Canarias University Canary Islands, Spain
| | - María Martel-Escobar
- Department of Quantitative Methods, Las Palmas de Gran Canarias University Canary Islands, Spain
| | - Ferran Barbe
- Respiratory Department, Institut de Recerca Biomédica de LLeida (IRBLLEIDA), Lleida, Spain; CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain
| | - Jaime Corral
- Respiratory Department, San Pedro de Alcántara Hospital, Cáceres, Spain; CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain; Instituto Universitario de Investigación Biosanitaria de Extremadura (INUBE), Cáceres, Spain
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20
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Masa JF, Pépin JL, Borel JC, Mokhlesi B, Murphy PB, Sánchez-Quiroga MÁ. Obesity hypoventilation syndrome. Eur Respir Rev 2019; 28:180097. [PMID: 30872398 PMCID: PMC9491327 DOI: 10.1183/16000617.0097-2018] [Citation(s) in RCA: 127] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2018] [Accepted: 01/23/2019] [Indexed: 12/18/2022] Open
Abstract
Obesity hypoventilation syndrome (OHS) is defined as a combination of obesity (body mass index ≥30 kg·m-2), daytime hypercapnia (arterial carbon dioxide tension ≥45 mmHg) and sleep disordered breathing, after ruling out other disorders that may cause alveolar hypoventilation. OHS prevalence has been estimated to be ∼0.4% of the adult population. OHS is typically diagnosed during an episode of acute-on-chronic hypercapnic respiratory failure or when symptoms lead to pulmonary or sleep consultation in stable conditions. The diagnosis is firmly established after arterial blood gases and a sleep study. The presence of daytime hypercapnia is explained by several co-existing mechanisms such as obesity-related changes in the respiratory system, alterations in respiratory drive and breathing abnormalities during sleep. The most frequent comorbidities are metabolic and cardiovascular, mainly heart failure, coronary disease and pulmonary hypertension. Both continuous positive airway pressure (CPAP) and noninvasive ventilation (NIV) improve clinical symptoms, quality of life, gas exchange, and sleep disordered breathing. CPAP is considered the first-line treatment modality for OHS phenotype with concomitant severe obstructive sleep apnoea, whereas NIV is preferred in the minority of OHS patients with hypoventilation during sleep with no or milder forms of obstructive sleep apnoea (approximately <30% of OHS patients). Acute-on-chronic hypercapnic respiratory failure is habitually treated with NIV. Appropriate management of comorbidities including medications and rehabilitation programmes are key issues for improving prognosis.
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Affiliation(s)
- Juan F Masa
- San Pedro de Alcántara Hospital, Cáceres, Spain
- CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain
- Instituto Universitario de Investigación Biosanitaria de Extremadura (INUBE) , Cáceres, Spain
| | - Jean-Louis Pépin
- Université Grenoble Alpes, HP2, Inserm U1042, Grenoble, France
- CHU de Grenoble, Laboratoire EFCR, Pôle Thorax et Vaisseaux, Grenoble, France
| | - Jean-Christian Borel
- Université Grenoble Alpes, HP2, Inserm U1042, Grenoble, France
- AGIR à dom. Association, Meylan, France
| | | | - Patrick B Murphy
- Guy's & St Thomas' NHS Foundation Trust, London, UK
- Centre for Human & Applied Physiological Sciences King's College London, London, UK
| | - Maria Ángeles Sánchez-Quiroga
- CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain
- Instituto Universitario de Investigación Biosanitaria de Extremadura (INUBE) , Cáceres, Spain
- Virgen del Puerto Hospital, Cáceres, Spain
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21
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Castellana G, Dragonieri S, Marra L, Quaranta VN, Carratù P, Ranieri T, Resta O. Nocturnal Hypoventilation May Have a Protective Effect on Ischemic Heart Disease in Patients with Obesity Hypoventilation Syndrome. Rejuvenation Res 2019; 22:13-19. [DOI: 10.1089/rej.2017.2030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Giorgio Castellana
- Institute of Respiratory Diseases, University of Bari “Aldo Moro,” Bari, Italy
| | - Silvano Dragonieri
- Institute of Respiratory Diseases, University of Bari “Aldo Moro,” Bari, Italy
| | - Lorenzo Marra
- Institute of Respiratory Diseases, University of Bari “Aldo Moro,” Bari, Italy
| | | | - Pierluigi Carratù
- Institute of Respiratory Diseases, University of Bari “Aldo Moro,” Bari, Italy
| | - Teresa Ranieri
- Institute of Respiratory Diseases, University of Bari “Aldo Moro,” Bari, Italy
| | - Onofrio Resta
- Institute of Respiratory Diseases, University of Bari “Aldo Moro,” Bari, Italy
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22
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Gursel G, Zerman A, Basarik B, Gonderen K, Aydogdu M, Memmedova S. Noninvasive auto-titrating ventilation (AVAPS-AE) versus average volume-assured pressure support (AVAPS) ventilation in hypercapnic respiratory failure patients. Intern Emerg Med 2018; 13:359-365. [PMID: 29512020 DOI: 10.1007/s11739-018-1821-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Accepted: 03/01/2018] [Indexed: 12/29/2022]
Abstract
Auto-titrating noninvasive ventilation (NIV) has been developed as a new mode applying variable expiratory-positive airway pressure (EPAP) in addition to variable inspiratory pressures (IPAP), both to deliver targeted tidal volume (VT) and to eliminate upper airway resistance. The purpose of this study is to evaluate whether NIV with auto-titrating mode will decrease more PaCO2 within a shorter time compared to volume-assured mode in hypercapnic intensive care unit (ICU) patients. The hypercapnic respiratory failure patients treated with average volume assured pressure support- automated EPAP mode (group1) were compared with those treated with average volume-assured pressure support mode (group2). Two groups were matched with each other according to baseline diagnoses, demographic characteristics, arterial blood gas values, target VT settings and daily NIV usage times. Built-in software was used to gather the ventilatory parameters. Twenty-eight patients were included in group 1, and 22 in group 2. The decrease in PaCO2 had been achieved within a shorter time period in group 1 (p < 0.05). This response was more pronounced within the first 6 h (mean reduction in PaCO2 was 7 ± 7 mmHg in group 1 and 2 ± 5 mmHg in group 2, p = 0.025), and significantly greater reductions in PaCO2 (18 ± 11 mmHg in group 1 and 9 ± 8 mmHg in group 2, p = 0.008) and plasma HCO3 levels (from 32 to 30 mEq and from 35 to 35 mEq, p = 0.007) took place within first 4 days. While mean IPAP was similar in both groups, maximum EPAP, mean VT and leak were significantly higher in group 1 than in group 2 (p < 0.05). Results of this preliminary study suggest that, this new auto-titrating NIV mode may provide additional benefit on volume-assured mode in decreasing PaCO2 more efficiently and rapidly in hypercapnic ICU patients.
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Affiliation(s)
- Gul Gursel
- Department of Pulmonary Critical Care Medicine, Gazi University School of Medicine, 11th Floor, Besevler, Ankara, Turkey
| | - Avsar Zerman
- Department of Pulmonary Critical Care Medicine, Gazi University School of Medicine, 11th Floor, Besevler, Ankara, Turkey
| | - Burcu Basarik
- Department of Pulmonary Critical Care Medicine, Gazi University School of Medicine, 11th Floor, Besevler, Ankara, Turkey
| | - Kamil Gonderen
- Department of Pulmonary Critical Care Medicine, Gazi University School of Medicine, 11th Floor, Besevler, Ankara, Turkey
| | - Muge Aydogdu
- Department of Pulmonary Critical Care Medicine, Gazi University School of Medicine, 11th Floor, Besevler, Ankara, Turkey.
| | - Serriyye Memmedova
- Department of Pulmonary Critical Care Medicine, Gazi University School of Medicine, 11th Floor, Besevler, Ankara, Turkey
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23
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Liu C, Chen MS, Yu H. The relationship between obstructive sleep apnea and obesity hypoventilation syndrome: a systematic review and meta-analysis. Oncotarget 2017; 8:93168-93178. [PMID: 29190986 PMCID: PMC5696252 DOI: 10.18632/oncotarget.21450] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2017] [Accepted: 09/12/2017] [Indexed: 01/22/2023] Open
Abstract
Obstructive Sleep Apnea and Obesity Hypoventilation Syndrome are two similar diseases. Obstructive Sleep Apnea has been receiving more and more attention while the diagnostic rate of Obesity Hypoventilation Syndrome is not high. Few studies directly evaluated the relationship between them. We systematically analyzed the relevance of the two diseases. MEDLINE®, EMBASE® and the Cochrane Library were carried out to find studies until May 2017. Pooled mean difference and 95% confidence interval were calculated to evaluate the value of clinical and physiologic variables in the prediction of Obesity Hypoventilation Syndrome. 9 Studies (n = 2085) fulfilled the predefined selection criteria. Totally 575 patients (28%) with Obesity Hypoventilation Syndrome were diagnosed from 2085 Obstructive Sleep Apnea patients. Among clearly diagnosed Obstructive Sleep Apnea patients, higher Body Mass Index levels(mean difference:4.72 kg/m2; 95% confidence interval: 4.26 to 5.17; p < 0.00001), higher Apnea-Hypopnea Index (mean difference: 8.36; 95% confidence interval: −3.88 to −2.84; p < 0.00001), greater neck circumference (mean difference:1.01; 95% confidence interval: 0.10 to 1.92; p = 0.03) and lower percent predicted FEV1 (mean difference:−10.28; 95% confidence interval:−11.33 to −9.22; p < 0.00001)were associated with the occurrence with obesity hypoventilation syndrome. We should be highly skeptical of obesity hypoventilation syndrome in Obstructive Sleep Apnea patients with these factors as early identification and appropriate treatment can improve prognosis.
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Affiliation(s)
- Chaoling Liu
- Respiratory Department, Guangdong Provincial Hospital of Chinese Medicine & the 2nd Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, 510120, China
| | - Mao-Sheng Chen
- Division of Chest Pain Center, Guangdong Provincial Hospital of Chinese Medicine & the 2nd Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, 510120, China
| | - Hui Yu
- Respiratory Department, Guangdong Provincial Hospital of Chinese Medicine & the 2nd Clinical College of Guangzhou University of Chinese Medicine, Guangzhou, 510120, China
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24
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Piper AJ, BaHammam AS, Javaheri S. Obesity Hypoventilation Syndrome: Choosing the Appropriate Treatment of a Heterogeneous Disorder. Sleep Med Clin 2017; 12:587-596. [PMID: 29108613 DOI: 10.1016/j.jsmc.2017.07.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The obesity hypoventilation syndrome (OHS) is associated with significant morbidity and increased mortality compared with simple obesity and eucapnic obstructive sleep apnea. Accurate diagnosis and commencement of early and appropriate management is fundamental in reducing the significant personal and societal burdens this disorder poses. Sleep disordered breathing is a major contributor to the developmental of sleep and awake hypercapnia, which characterizes OHS, and is effectively addressed through the use of positive airway pressure (PAP) therapy. This article reviews the current evidence supporting different modes of PAP currently used in managing these individuals.
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Affiliation(s)
- Amanda J Piper
- Sleep Unit, Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Missenden Road, Camperdown, New South Wales 2050, Australia; Central Medical School, University of Sydney, Sydney 2006, New South Wales, Australia.
| | - Ahmed S BaHammam
- The University Sleep Disorders Center, Department of Medicine, College of Medicine, King Saud University, Riyadh 11324, Saudi Arabia; National Plan for Science and Technology, King Saud University, Riyadh 11324, Saudi Arabia
| | - Shahrokh Javaheri
- Montgomery Sleep Laboratory, Bethesda North Hospital, Cincinnati, OH 45242, USA; Pulmonary and Sleep Medicine, University of Cincinnati, Cincinnati, OH, USA; Division of Cardiology, Ohio State University, Columbus, OH, USA
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25
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Liu NC, Oechtering GU, Adams VJ, Kalmar L, Sargan DR, Ladlow JF. Outcomes and prognostic factors of surgical treatments for brachycephalic obstructive airway syndrome in 3 breeds. Vet Surg 2017; 46:271-280. [PMID: 28146288 DOI: 10.1111/vsu.12608] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 08/16/2016] [Accepted: 10/26/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To determine prognostic indicators for the surgical treatment of brachycephalic obstructive airway syndrome (BOAS) and to compare the prognosis of 2 multilevel surgical procedures. STUDY DESIGN Prospective clinical study. SAMPLE POPULATION Client-owned pugs, French bulldogs, and bulldogs (n = 50). METHODS Noninvasive whole-body barometric plethysmography (WBBP) was used to assess respiratory function before, 1 month and 6 months after upper airway corrective surgery. Postoperatively, BOAS indices (ie, ascending severity score generated from WBBP data, 0%-100%) that equaled to or exceeded the cut-off values of BOAS in the diagnostic models were considered to have a "poor prognosis." A multivariate logistic regression was used to assess predictors for prognosis. RESULTS The median BOAS indices decreased after surgery (from 76% to 63%, P < .0001), although dogs with indices in this range would still be considered clinically affected. Age (odds ratios [OR] = 0.96, 95% confidence interval [CI]: 0.93-0.99, P < .05), body condition (OR = 0.06, 95% CI: 0.01-0.39, P < .01), laryngeal collapse (OR = 6.1, 95% CI: 1-37.22, P < .05), and surgical techniques (OR = 7.94, 95% CI: 1.17-54.01, P < .05) were associated with postoperative prognosis. The multivariate model suggests modified multilevel surgery (MMS) may have a better outcome than traditional multilevel surgery (TMS) (P = .034). The positive predictive value of the logistic model was 84% (95% CI: 68-94%) and the area under the receiver operating characteristic (ROC) curve was 89% (95% CI: 78-99%, P <.0001). CONCLUSIONS Younger age, normal body condition, presence of laryngeal collapse, and treatment with TMS were negative prognostic factors after surgical treatment of BOAS. MMS is recommended, particularly in dogs with a higher probability of poor prognosis.
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Affiliation(s)
- Nai-Chieh Liu
- Department of Veterinary Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Gerhard U Oechtering
- Small Animal Department, Ear Nose and Throat Unit, Faculty of Veterinary Medicine, University of Leipzig, Leipzig, Germany
| | | | - Lajos Kalmar
- Department of Veterinary Medicine, University of Cambridge, Cambridge, United Kingdom
| | - David R Sargan
- Department of Veterinary Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Jane F Ladlow
- Department of Veterinary Medicine, University of Cambridge, Cambridge, United Kingdom.,Queen's Veterinary School Hospital, University of Cambridge, Cambridge, United Kingdom
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26
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Ramírez-Molina VR, Gómez-de-Terreros FJ, Barca-Durán J, Masa JF. Non-invasive Positive Airway Pressure in Obesity Hypoventilation Syndrome and Chronic Obstructive Pulmonary Disease: Present and Future Perspectives. COPD 2017; 14:418-428. [DOI: 10.1080/15412555.2017.1317730] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Affiliation(s)
- Victor R. Ramírez-Molina
- Clinica de Trastornos Respiratorios del Dormir, Instituto Nacional de Enfermedades Respiratorias ‘Ismael Cosio Villegas’, Ciudad de Mexico, Mexico
| | | | - Javier Barca-Durán
- University of Extremadura, Cáceres, Spain
- Coordinator of the Research Group on Bio-Anthropology and Cardiovascular Sciences, University of Extremadura, Cáceres, Spain
| | - Juan F. Masa
- Sleep Unit, San Pedro de Alcantara Hospital, Cáceres, Spain
- CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain
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27
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Schenk P, Eber E, Funk GC, Fritz W, Hartl S, Heininger P, Kink E, Kühteubl G, Oberwaldner B, Pachernigg U, Pfleger A, Schandl P, Schmidt I, Stein M. [Non-invasive and invasive out of hospital ventilation in chronic respiratory failure : Consensus report of the working group on ventilation and intensive care medicine of the Austrian Society of Pneumology]. Wien Klin Wochenschr 2016; 128 Suppl 1:S1-36. [PMID: 26837865 DOI: 10.1007/s00508-015-0899-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The current consensus report was compiled under the patronage of the Austrian Society of Pneumology (Österreichischen Gesellschaft für Pneumologie, ÖGP) with the intention of providing practical guidelines for out-of-hospital ventilation that are in accordance with specific Austrian framework parameters and legal foundations. The guidelines are oriented toward a 2004 consensus ÖGP recommendation concerning the setup of long-term ventilated patients and the 2010 German Respiratory Society S2 guidelines on noninvasive and invasive ventilation of chronic respiratory insufficiency, adapted to national experiences and updated according to recent literature. In 11 chapters, the initiation, adjustment, and monitoring of out-of-hospital ventilation is described, as is the technical equipment and airway access. Additionally, the different indications-such as chronic obstructive pulmonary diseases, thoracic restrictive and neuromuscular diseases, obesity hypoventilation syndrome, and pediatric diseases-are discussed. Furthermore, the respiratory physiotherapy of adults and children on invasive and noninvasive long-term ventilation is addressed in detail.
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Affiliation(s)
- Peter Schenk
- Abteilung für Pulmologie, Landesklinikum Hochegg, Hocheggerstraße 88, 2840, Grimmenstein, Österreich.
| | - Ernst Eber
- Klinische Abteilung für Pädiatrische Pulmonologie und Allergologie, Universitätsklinik für Kinder- und Jugendheilkunde, Medizinische Universität Graz, Graz, Österreich
| | - Georg-Christian Funk
- I. Interne Lungenabteilung, Pulmologisches Zentrum, Sozialmedizinisches Zentrum Baumgartner Höhe, Otto Wagner Spital, Wien, Österreich
| | - Wilfried Fritz
- Klinische Abteilung für Lungenkrankheiten, Universitätsklinik für Innere Medizin, Universitätsklinikum Graz, Graz, Österreich
| | - Sylvia Hartl
- I. Interne Lungenabteilung, Pulmologisches Zentrum, Sozialmedizinisches Zentrum Baumgartner Höhe, Otto Wagner Spital, Wien, Österreich
| | | | - Eveline Kink
- Abteilung für Lungenkrankheiten, Landeskrankenhaus Hörgas-Enzenbach, Eisbach, Österreich
| | - Gernot Kühteubl
- Abteilung für Pulmologie, Landesklinikum Hochegg, Hocheggerstraße 88, 2840, Grimmenstein, Österreich
| | | | - Ulrike Pachernigg
- Klinische Abteilung für Pädiatrische Pulmonologie und Allergologie, Universitätsklinik für Kinder- und Jugendheilkunde, Medizinische Universität Graz, Graz, Österreich
| | - Andreas Pfleger
- Klinische Abteilung für Pädiatrische Pulmonologie und Allergologie, Universitätsklinik für Kinder- und Jugendheilkunde, Medizinische Universität Graz, Graz, Österreich
| | - Petra Schandl
- 1. Allgemeine Intensivstation, Wilhelminenspital, Wien, Österreich
| | - Ingrid Schmidt
- I. Interne Lungenabteilung, Pulmologisches Zentrum, Sozialmedizinisches Zentrum Baumgartner Höhe, Otto Wagner Spital, Wien, Österreich
| | - Markus Stein
- Abteilung für Pneumologie, Landeskrankenhaus Hochzirl-Natters, Standort Natters, Natters, Österreich
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28
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Sequeira TCA, BaHammam AS, Esquinas AM. Noninvasive Ventilation in the Critically Ill Patient With Obesity Hypoventilation Syndrome: A Review. J Intensive Care Med 2016; 32:421-428. [PMID: 27530511 DOI: 10.1177/0885066616663179] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Obesity is a global epidemic that adversely affects respiratory physiology. Sleep-disordered breathing and obesity hypoventilation syndrome (OHS) are among the most common pulmonary complications related to obesity class III. Patients with OHS may present with acute hypercapnic respiratory failure (AHRF) that necessitates immediate noninvasive ventilation (NIV) or invasive ventilation and intensive care unit (ICU) monitoring. The OHS is underrecognized as a cause of AHRF. The management of mechanical ventilation in obese ICU patients is one of the most challenging problems facing respirologists, intensivists, and anesthesiologists. The treatment of AHRF in patients with OHS should aim to improve alveolar ventilation with better alveolar gas exchange, as well as maintaining a patent upper airway, which is ideally achieved through NIV. Treatment with NIV is associated with improvement in blood gases and lung mechanics and may reduce hospital admissions and morbidity. In this review, we will address 3 main issues: (1) NIV of critically ill patients with acute respiratory failure and OHS; (2) the indications for postoperative application of NIV in patients with OHS; and (3) the impact of OHS on weaning and postextubation respiratory failure. Additionally, the authors propose an algorithm for the management of obese patients with AHRF.
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Affiliation(s)
- Telma C A Sequeira
- 1 Pulmonology Department, Hospital Prof. Doutor Fernando Fonseca, EPE, Amadora, Lisbon, Portugal.,2 Faculdade Medicina de Lisboa, Universidade de Lisboa, Lisbon, Portugal
| | - Ahmed S BaHammam
- 3 The University Sleep Disorders Center, Riyadh, Saudi Arabia.,4 Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia.,5 Strategic Technologies Program of the National Plan for Sciences and Technology and Innovation in the Kingdom of Saudi Arabia, Riyadh, Saudi Arabia
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Masa JF, Corral J, Caballero C, Barrot E, Terán-Santos J, Alonso-Álvarez ML, Gomez-Garcia T, González M, López-Martín S, De Lucas P, Marin JM, Marti S, Díaz-Cambriles T, Chiner E, Egea C, Miranda E, Mokhlesi B, García-Ledesma E, Sánchez-Quiroga MÁ, Ordax E, González-Mangado N, Troncoso MF, Martinez-Martinez MÁ, Cantalejo O, Ojeda E, Carrizo SJ, Gallego B, Pallero M, Ramón MA, Díaz-de-Atauri J, Muñoz-Méndez J, Senent C, Sancho-Chust JN, Ribas-Solís FJ, Romero A, Benítez JM, Sanchez-Gómez J, Golpe R, Santiago-Recuerda A, Gomez S, Bengoa M. Non-invasive ventilation in obesity hypoventilation syndrome without severe obstructive sleep apnoea. Thorax 2016; 71:899-906. [PMID: 27406165 PMCID: PMC5036235 DOI: 10.1136/thoraxjnl-2016-208501] [Citation(s) in RCA: 72] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 06/17/2016] [Indexed: 01/05/2023]
Abstract
Background Non-invasive ventilation (NIV) is an effective form of treatment in patients with obesity hypoventilation syndrome (OHS) who have concomitant severe obstructive sleep apnoea (OSA). However, there is a paucity of evidence on the efficacy of NIV in patients with OHS without severe OSA. We performed a multicentre randomised clinical trial to determine the comparative efficacy of NIV versus lifestyle modification (control group) using daytime arterial carbon dioxide tension (PaCO2) as the main outcome measure. Methods Between May 2009 and December 2014 we sequentially screened patients with OHS without severe OSA. Participants were randomised to NIV versus lifestyle modification and were followed for 2 months. Arterial blood gas parameters, clinical symptoms, health-related quality of life assessments, polysomnography, spirometry, 6-min walk distance test, blood pressure measurements and healthcare resource utilisation were evaluated. Statistical analysis was performed using intention-to-treat analysis. Results A total of 365 patients were screened of whom 58 were excluded. Severe OSA was present in 221 and the remaining 86 patients without severe OSA were randomised. NIV led to a significantly larger improvement in PaCO2 of −6 (95% CI −7.7 to −4.2) mm Hg versus −2.8 (95% CI −4.3 to −1.3) mm Hg, (p<0.001) and serum bicarbonate of −3.4 (95% CI −4.5 to −2.3) versus −1 (95% CI −1.7 to −0.2 95% CI) mmol/L (p<0.001). PaCO2 change adjusted for NIV compliance did not further improve the inter-group statistical significance. Sleepiness, some health-related quality of life assessments and polysomnographic parameters improved significantly more with NIV than with lifestyle modification. Additionally, there was a tendency towards lower healthcare resource utilisation in the NIV group. Conclusions NIV is more effective than lifestyle modification in improving daytime PaCO2, sleepiness and polysomnographic parameters. Long-term prospective studies are necessary to determine whether NIV reduces healthcare resource utilisation, cardiovascular events and mortality. Trial registration number NCT01405976; results.
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Affiliation(s)
- Juan F Masa
- San Pedro de Alcántara Hospital, Cáceres, Spain Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | - Jaime Corral
- San Pedro de Alcántara Hospital, Cáceres, Spain Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain
| | | | | | - Joaquin Terán-Santos
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain University Hospital, Burgos, Spain
| | - Maria L Alonso-Álvarez
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain University Hospital, Burgos, Spain
| | | | | | | | | | - José M Marin
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain Miguel Servet Hospital, Zaragoza, Spain
| | - Sergi Marti
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain Valld'Hebron Hospital, Barcelona, Spain
| | - Trinidad Díaz-Cambriles
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain Doce de Octubre Hospital, Madrid, Spain
| | | | - Carlos Egea
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain Sleep Unit and Respiratory Department, Alava University Hospital IRB, Vitoria, Spain
| | - Erika Miranda
- Araba Health Research Unit, Osakidetza, Alava Hospital, Spain
| | - Babak Mokhlesi
- Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago, Chicago, Illinois, USA
| | | | | | | | - Estrella Ordax
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain University Hospital, Burgos, Spain
| | - Nicolás González-Mangado
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain IIS Fundación Jiménez Díaz, Madrid, Spain
| | - Maria F Troncoso
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain IIS Fundación Jiménez Díaz, Madrid, Spain
| | | | | | | | - Santiago J Carrizo
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain Miguel Servet Hospital, Zaragoza, Spain
| | | | - Mercedes Pallero
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain Valld'Hebron Hospital, Barcelona, Spain
| | - M Antonia Ramón
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain Valld'Hebron Hospital, Barcelona, Spain
| | - Josefa Díaz-de-Atauri
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain Doce de Octubre Hospital, Madrid, Spain
| | - Jesús Muñoz-Méndez
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain Doce de Octubre Hospital, Madrid, Spain
| | | | | | | | | | | | | | - Rafael Golpe
- Lucus Augusti Universitary Hospital, Lugo, Spain
| | | | - Silvia Gomez
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Madrid, Spain Arnau de Vilanova Hospital, Lleida, Spain
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Georges M, Nguyen-Baranoff D, Griffon L, Foignot C, Bonniaud P, Camus P, Pepin JL, Rabec C. Usefulness of transcutaneous PCO2to assess nocturnal hypoventilation in restrictive lung disorders. Respirology 2016; 21:1300-6. [DOI: 10.1111/resp.12812] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2015] [Revised: 02/04/2016] [Accepted: 02/12/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Marjolaine Georges
- Pulmonary Departement and Respiratory Critical Care Unit; University Hospital Dijon; Dijon France
- School of Medicine; Inserm U 866; University of Burgundy; Dijon France
| | - Danièle Nguyen-Baranoff
- Pulmonary Departement and Respiratory Critical Care Unit; University Hospital Dijon; Dijon France
| | - Lucie Griffon
- Pulmonary Departement and Respiratory Critical Care Unit; University Hospital Dijon; Dijon France
| | - Clement Foignot
- Pulmonary Departement and Respiratory Critical Care Unit; University Hospital Dijon; Dijon France
| | - Philippe Bonniaud
- Pulmonary Departement and Respiratory Critical Care Unit; University Hospital Dijon; Dijon France
- School of Medicine; Inserm U 866; University of Burgundy; Dijon France
| | - Philippe Camus
- Pulmonary Departement and Respiratory Critical Care Unit; University Hospital Dijon; Dijon France
- School of Medicine; Inserm U 866; University of Burgundy; Dijon France
| | - Jean-Louis Pepin
- Sleep, Exercise and Physiology Laboratory, EFCR; Grenoble University Hospital; Grenoble France
- Inserm U 1042, HP2; University of Grenoble Alpes; Grenoble France
| | - Claudio Rabec
- Pulmonary Departement and Respiratory Critical Care Unit; University Hospital Dijon; Dijon France
- School of Medicine; Inserm U 866; University of Burgundy; Dijon France
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Mid- and Long-term Efficacy of Non-invasive Ventilation in Obesity Hypoventilation Syndrome: The Pickwick's Study. ACTA ACUST UNITED AC 2016. [DOI: 10.1016/j.arbr.2016.01.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Manuel AR, Hart N, Stradling JR. Correlates of obesity-related chronic ventilatory failure. BMJ Open Respir Res 2016; 3:e000110. [PMID: 26918192 PMCID: PMC4762144 DOI: 10.1136/bmjresp-2015-000110] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Revised: 12/08/2015] [Accepted: 12/11/2015] [Indexed: 12/12/2022] Open
Abstract
Introduction Only a third of obese patients develop chronic ventilatory failure. This cross-sectional study assessed multiple factors potentially associated with chronic ventilatory failure. Materials/patients and methods Participants had a body mass index (BMI) >30 kg/m2, with or without chronic ventilatory failure (awake arterial partial pressure of carbon dioxide >6 kPa or base excess (BE) ≥2 mmols/L). Factors investigated were grouped into domains: (1) obesity measures, (2) pulmonary function, (3) respiratory and non-respiratory muscle strength, (4) sleep study derivatives, (5) hypoxic and hypercapnic responses, and (6) some hormonal, nutritional and inflammatory measures. Results 71 obese participants (52% male) were studied over 27 months, 52 (SD 9) years and BMI 47 (range 32–74) kg/m2. The best univariate correlates of BE from each domain were: (1) dual-energy X-ray absorptiometry measurement of visceral fat (r=+0.50, p=0.001); (2) supine forced expiratory volume in 1 s (r=−0.40, p=0.001); (3) sniff maximum pressure (r=−0.28, p=0.02); (4) mean overnight arterial oxygen saturation (r=−0.50, p<0.001); (5) ventilatory response to 15% O2 breathing (r=−0.28, p=0.02); and (6) vitamin D (r=−0.30, p=0.01). In multivariate analysis, only visceral fat and ventilatory response to hypoxia remained significant. Conclusions We have confirmed that in the obese, BMI is a poor correlate of chronic ventilatory failure, and the best independent correlates are visceral fat and hypoxic ventilatory response. Trial registration number NCT01380418.
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Affiliation(s)
- Ari R Manuel
- Oxford Centre for Respiratory Medicine, NIHR Oxford Biomedical Research Centre, Oxford University Churchill Campus, and Oxford University Hospitals NHS Trust , Oxford , UK
| | - Nicholas Hart
- Lane Fox Clinical Respiratory Physiology Centre, St Thomas' Hospital, Guy's & St Thomas' NHS Foundation Trust , London , UK
| | - John R Stradling
- Oxford Centre for Respiratory Medicine, NIHR Oxford Biomedical Research Centre, Oxford University Churchill Campus, and Oxford University Hospitals NHS Trust , Oxford , UK
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López-Jiménez MJ, Masa JF, Corral J, Terán J, Ordaz E, Troncoso MF, González-Mangado N, González M, Lopez-Martínez S, De Lucas P, Marín JM, Martí S, Díaz-Cambriles T, Díaz-de-Atauri J, Chiner E, Aizpuru F, Egea C, Romero A, Benítez JM, Sánchez-Gómez J, Golpe R, Santiago-Recuerda A, Gómez S, Barbe F, Bengoa M. Mid- and Long-Term Efficacy of Non-Invasive Ventilation in Obesity Hypoventilation Syndrome: The Pickwick's Study. Arch Bronconeumol 2015; 52:158-65. [PMID: 26656679 DOI: 10.1016/j.arbres.2015.10.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2015] [Revised: 10/13/2015] [Accepted: 10/14/2015] [Indexed: 01/23/2023]
Abstract
The Pickwick project was a prospective, randomized and controlled study, which addressed the issue of obesity hypoventilation syndrome (OHS), a growing problem in developed countries. OHS patients were divided according to apnea-hypopnea index (AHI) ≥30 and <30 determined by polysomnography. The group with AHI≥30 was randomized to intervention with lifestyle changes, noninvasive ventilation (NIV) or continuous positive airway pressure (CPAP); the group with AHI<30 received NIV or lifestyle changes. The aim of the study was to evaluate the efficacy of NIV treatment, CPAP and lifestyle changes (control) in the medium and long-term management of patients with OHS. The primary variables were PaCO2 and days of hospitalization, and operating variables were the percentage of dropouts for medical reasons and mortality. Secondary medium-term objectives were: (i)to evaluate clinical-functional effectiveness on quality of life, echocardiographic and polysomnographic variables; (ii)to investigate the importance of apneic events and leptin in the pathogenesis of daytime alveolar hypoventilation and change according to the different treatments; (ii)to investigate whether metabolic, biochemical and vascular endothelial dysfunction disorders depend on the presence of apneas and hypopneasm and (iv)changes in inflammatory markers and endothelial damage according to treatment. Secondary long-term objectives were to evaluate: (i)clinical and functional effectiveness and quality of life with NIV and CPAP; (ii)changes in leptin, inflammatory markers and endothelial damage according to treatment; (iii)changes in pulmonary hypertension and other echocardiographic variables, as well as blood pressure and incidence of cardiovascular events, and (iv)dropout rate and mortality.
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Affiliation(s)
| | - Juan F Masa
- Servicio de Neumología, Hospital San Pedro de Alcántara, Cáceres, España; CIBER de Enfermedades Respiratorias (CIBERES), Madrid, España.
| | - Jaime Corral
- Servicio de Neumología, Hospital San Pedro de Alcántara, Cáceres, España; CIBER de Enfermedades Respiratorias (CIBERES), Madrid, España
| | - Joaquín Terán
- Unidad del Sueño, Complejo Asistencial de Burgos, Burgos, España; CIBER de Enfermedades Respiratorias (CIBERES), Madrid, España
| | - Estrella Ordaz
- Unidad del Sueño, Complejo Asistencial de Burgos, Burgos, España; CIBER de Enfermedades Respiratorias (CIBERES), Madrid, España
| | - Maria F Troncoso
- Sección de Neumología, IIS Fundación Jiménez Díaz, Madrid, España; CIBER de Enfermedades Respiratorias (CIBERES), Madrid, España
| | - Nicolás González-Mangado
- Sección de Neumología, IIS Fundación Jiménez Díaz, Madrid, España; CIBER de Enfermedades Respiratorias (CIBERES), Madrid, España
| | - Mónica González
- Unidad de Sueño y Ventilación, Servicio de Neumología, Hospital Universitario Marqués de Valdecilla, Santander, Cantabria, España
| | | | - Pilar De Lucas
- Servicio de Neumología, Hospital Gregorio Marañón, Madrid, España
| | - José M Marín
- Servicio de Neumología, Hospital Miguel Servet, Zaragoza, España; CIBER de Enfermedades Respiratorias (CIBERES), Madrid, España
| | - Sergi Martí
- Servicio de Neumología, Hospital Vall d'Hebron, Barcelona, España; CIBER de Enfermedades Respiratorias (CIBERES), Madrid, España
| | - Trinidad Díaz-Cambriles
- Servicio de Neumología, Hospital Doce de Octubre, Madrid, España; CIBER de Enfermedades Respiratorias (CIBERES), Madrid, España
| | - Josefa Díaz-de-Atauri
- Servicio de Neumología, Hospital Doce de Octubre, Madrid, España; CIBER de Enfermedades Respiratorias (CIBERES), Madrid, España
| | - Eusebi Chiner
- Servicio de Neumología, Hospital San Juan, Alicante, España
| | - Felipe Aizpuru
- Unidad de Investigación de Araba, Departamento de Estadística, Hospital Álava, Vitoria-Gasteiz, España; CIBER de Enfermedades Respiratorias (CIBERES), Madrid, España
| | - Carlos Egea
- Unidad de Sueño, Departamento de Neumología, Hospital Universitario de Álava IRB, Vitoria-Gasteiz, España; CIBER de Enfermedades Respiratorias (CIBERES), Madrid, España
| | - Auxiliadora Romero
- Unidad de Sueño de la Unidad Médico-Quirúrgica de Enfermedades respiratorias, Hospital Virgen del Rocío, Sevilla, España
| | - José M Benítez
- Servicio de Neumología, Hospital Universitario Virgen Macarena, Sevilla, España
| | - Jesús Sánchez-Gómez
- Servicio de Neumología, Hospital Universitario Virgen Macarena, Sevilla, España
| | - Rafael Golpe
- Servicio de Neumología, Hospital Universitario Lucus Augusti, Lugo, España
| | | | - Silvia Gómez
- Servicio de Neumología, Hospital Arnau de Vilanova, Lleida, España; CIBER de Enfermedades Respiratorias (CIBERES), Madrid, España
| | - Ferrán Barbe
- Servicio de Neumología, Hospital Arnau de Vilanova, Lleida, España; CIBER de Enfermedades Respiratorias (CIBERES), Madrid, España
| | - Mónica Bengoa
- Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, España
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Palen BN, Kapur VK. Tailoring Therapy for Obesity Hypoventilation Syndrome. Am J Respir Crit Care Med 2015; 192:8-10. [PMID: 26131989 DOI: 10.1164/rccm.201504-0721ed] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Affiliation(s)
- Brian N Palen
- 1 Division of Pulmonary and Critical Care Medicine University of Washington Seattle, Washington and.,2 Veterans Affairs Puget Sound Health Care System Seattle, Washington
| | - Vishesh K Kapur
- 1 Division of Pulmonary and Critical Care Medicine University of Washington Seattle, Washington and
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Masa JF, Corral J, Alonso ML, Ordax E, Troncoso MF, Gonzalez M, Lopez-Martínez S, Marin JM, Marti S, Díaz-Cambriles T, Chiner E, Aizpuru F, Egea C. Efficacy of Different Treatment Alternatives for Obesity Hypoventilation Syndrome. Pickwick Study. Am J Respir Crit Care Med 2015; 192:86-95. [DOI: 10.1164/rccm.201410-1900oc] [Citation(s) in RCA: 168] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Bingol Z, Pıhtılı A, Kıyan E. Modified STOP-BANG questionnaire to predict obesity hypoventilation syndrome in obese subjects with obstructive sleep apnea. Sleep Breath 2015; 20:495-500. [DOI: 10.1007/s11325-015-1213-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2015] [Revised: 05/15/2015] [Accepted: 05/29/2015] [Indexed: 10/23/2022]
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Abstract
This article summarizes available data on the obesity hypoventilation syndrome and its pertinence to intensivists, outlines clinical and pathophysiologic aspects of the disease, discusses multidisciplinary treatments, and reviews the available literature on outcomes specific to the critically ill patient.
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Affiliation(s)
- Shirley F Jones
- Division of Pulmonary Critical Care and Sleep Medicine, Department of Medicine, Baylor Scott &White Health, Texas A&M Health Science Center, 2401 South 31st Street, Temple, TX 76508, USA.
| | - Veronica Brito
- Division of Pulmonary Critical Care and Sleep Medicine, Department of Medicine, Baylor Scott &White Health, Texas A&M Health Science Center, 2401 South 31st Street, Temple, TX 76508, USA
| | - Shekhar Ghamande
- Division of Pulmonary Critical Care and Sleep Medicine, Department of Medicine, Baylor Scott &White Health, Texas A&M Health Science Center, 2401 South 31st Street, Temple, TX 76508, USA
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Noninvasive Mechanical Ventilation in Patients With Obesity Hypoventilation Syndrome. Long-term Outcome and Prognostic Factors. ACTA ACUST UNITED AC 2015. [DOI: 10.1016/j.arbr.2014.06.016] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Manuel AR, Hart N, Stradling JR. Is a Raised Bicarbonate, Without Hypercapnia, Part of the Physiologic Spectrum of Obesity-Related Hypoventilation? Chest 2015; 147:362-368. [DOI: 10.1378/chest.14-1279] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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Abstract
Obesity hypoventilation syndrome is a respiratory consequence of morbid obesity that is characterized by alveolar hypoventilation during sleep and wakefulness. The disorder involves a complex interaction between impaired respiratory mechanics, ventilatory drive and sleep-disordered breathing. Early diagnosis and treatment is important, because delay in treatment is associated with significant mortality and morbidity. Available treatment options include non-invasive positive airway pressure (PAP) therapies and weight loss. There is limited long-term data regarding the effectiveness of such therapies. This review outlines the current concepts of clinical presentation, diagnostic and management strategies to help identify and treat patients with obesity-hypoventilation syndromes.
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Kato T, Suda S, Kasai T. Positive airway pressure therapy for heart failure. World J Cardiol 2014; 6:1175-91. [PMID: 25429330 PMCID: PMC4244615 DOI: 10.4330/wjc.v6.i11.1175] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2014] [Revised: 07/16/2014] [Accepted: 09/18/2014] [Indexed: 02/06/2023] Open
Abstract
Heart failure (HF) is a life-threatening disease and is a growing public health concern. Despite recent advances in pharmacological management for HF, the morbidity and mortality from HF remain high. Therefore, non-pharmacological approaches for HF are being developed. However, most non-pharmacological approaches are invasive, have limited indication and are considered only for advanced HF. Accordingly, the development of less invasive, non-pharmacological approaches that improve outcomes for patients with HF is important. One such approach may include positive airway pressure (PAP) therapy. In this review, the role of PAP therapy applied through mask interfaces in the wide spectrum of HF care is discussed.
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Affiliation(s)
- Takao Kato
- Takao Kato, Department of Cardiology, Juntendo University School of Medicine, Tokyo 113-8421, Japan
| | - Shoko Suda
- Takao Kato, Department of Cardiology, Juntendo University School of Medicine, Tokyo 113-8421, Japan
| | - Takatoshi Kasai
- Takao Kato, Department of Cardiology, Juntendo University School of Medicine, Tokyo 113-8421, Japan
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Lobato SD, Alises SM. Non-invasive positive pressure ventilation for severe COPD. THE LANCET. RESPIRATORY MEDICINE 2014; 2:e17-e18. [PMID: 25298060 DOI: 10.1016/s2213-2600(14)70200-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
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Respiratory Determinants of Diurnal Hypercapnia in Obesity Hypoventilation Syndrome. What Does Weight Have to Do with It? Ann Am Thorac Soc 2014; 11:945-50. [DOI: 10.1513/annalsats.201403-099oc] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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Khan A, Morgenthaler TI, Ramar K. Sleep disordered breathing in isolated unilateral and bilateral diaphragmatic dysfunction. J Clin Sleep Med 2014; 10:509-15. [PMID: 24910552 PMCID: PMC4046357 DOI: 10.5664/jcsm.3698] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION The effect of isolated unilateral or bilateral diaphragmatic dysfunction (DD), in the absence of a generalized neuromuscular disorder, on sleep disordered breathing (SDB) is not well understood. The type of positive airway pressure (PAP) device needed to treat SDB in patients with isolated DD is also not well established. METHODS We retrospectively analyzed data on patients with isolated unilateral or bilateral DD who were referred for polysomnography (PSG) for clinical symptoms or abnormal oximetry between 1994 and 2006. RESULTS We found 66 patients who met criteria, of whom 74.2% were males with an average age of 58.8 ± 10.9 years. 56 had isolated unilateral DD, and 10 had isolated bilateral DD. All had significant SDB with an apnea-hypopnea index (AHI) of 26.6 ± 28.4. There were no significant differences in PSG measures, arterial blood gas analysis, pulmonary function tests, or echocardiographic data, except for lower maximal inspiratory pressure in patients with bilateral DD compared to unilateral DD (40.2% ± 17.8% vs. 57.7% ± 20.5%, p = 0.02). Control of SDB with continuous PAP (CPAP) was possible in only 37.9% of patients with the rest requiring bilevel PAP (BPAP). Patients with isolated bilateral DD and SDB were 6.8 times more likely to fail CPAP than those with unilateral DD (p = 0.03). CONCLUSIONS Most patients with isolated DD failed CPAP and required BPAP. Patients with bilateral DD were more likely to require BPAP than those with unilateral DD. Patients with isolated DD should be considered for in-lab titration to determine adequacy of therapy.
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Affiliation(s)
- Akram Khan
- Division of Pulmonary and Critical Care Medicine, Oregon Health Science Center, Portland, OR
| | - Timothy I. Morgenthaler
- Center for Sleep Medicine, Division of Pulmonary and Critical Care, Mayo Clinic, Rochester, MN
| | - Kannan Ramar
- Center for Sleep Medicine, Division of Pulmonary and Critical Care, Mayo Clinic, Rochester, MN
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Noninvasive mechanical ventilation in patients with obesity hypoventilation syndrome. Long-term outcome and prognostic factors. Arch Bronconeumol 2014; 51:61-68. [PMID: 24703500 DOI: 10.1016/j.arbres.2014.02.015] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2013] [Revised: 01/12/2014] [Accepted: 02/13/2014] [Indexed: 11/23/2022]
Abstract
INTRODUCTION Obesity is associated with 2 closely related respiratory diseases: obesity hypoventilation syndrome (OHS) and obstructive sleep apnea-hypopnea syndrome (OSAHS). It has been shown that noninvasive ventilation during sleep produces clinical and functional improvement in these patients. The long-term survival rate with this treatment, and the difference in clinical progress in OHS patients with and without OSAHS are analyzed. METHODOLOGY Longitudinal, observational study with a cohort of patients diagnosed with OHS, included in a home ventilation program over a period of 12 years, divided into 2 groups: pure OHS and OSAHS-associated OHS. Bi-level positive airway pressure ventilation was administered. During the follow-up period, symptoms, exacerbations and hospitalizations, blood gas tests and pulmonary function tests, and survival rates were monitored and compared. RESULTS Eighty-three patients were eligible for analysis, 60 women (72.3%) and 23 men (27.7%), with a mean survival time of 8.47 years. Fifty patients (60.2%) were included in the group without OSAHS (OHS) and 33 (39.8%) in the OSAHS-associated OHS group (OHS-OSAHS). PaCO₂ in the OHS group was significantly higher than in the OHS-OSAHS group (P<.01). OHS patients also had a higher hospitalization rate (P<.05). There was a significant improvement in both groups in FEV₁ and FVC, and no differences between groups in PaCO₂ and PaO₂ values. There were no differences in mortality between the 2 groups, but low FVC values were predictive of mortality. CONCLUSIONS The use of mechanical ventilation in patients with OHS, with or without OSAHS, is an effective treatment for the correction of blood gases and functional alterations and can achieve prolonged survival rates.
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