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da Silva DIC, Ishimoto LY, Franco EAT, dos Santos MSC, Brizola LFP, Colombo CA, Savadkouhi EG, Machado LHS, Tanni SE, Prudente R. Long-term oxygen therapy to reduce length of hospital stay in COVID-19. REVISTA DA ASSOCIACAO MEDICA BRASILEIRA (1992) 2024; 70:e20231379. [PMID: 39045926 PMCID: PMC11262311 DOI: 10.1590/1806-9282.20231379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2024] [Accepted: 03/24/2024] [Indexed: 07/25/2024]
Abstract
OBJECTIVE The aim of this study was to evaluate the efficacy of long-term oxygen therapy as a strategy to reduce hospitalization time in patients affected by COVID-19. METHODS Between April and December 2021, COVID-19 patients with stable clinical conditions needing supplementary oxygen therapy during hospitalization were oriented to have hospital discharge with long-term oxygen therapy and reassessment after 15 days. RESULTS A total of 62 patients were evaluated and, 15 days after discharge, 69% of patients had suspended long-term oxygen therapy, with no difference between the groups admitted to the intensive care unit or the ward (p=0.319). Among the individuals who needed to maintain long-term oxygen therapy, in addition to worse P/F ratio (265±57 vs. 345±51; p<0.001) and lower partial pressure of oxygen (55±12 vs. 72±11 mmHg; p<0.001), were those more obese (37±8 vs. 30±6 kg/m2; p=0.032), needed more time for invasive mechanical ventilation (46±27 vs. 20±16 days; p=0.029), had greater persistence of symptoms (p<0.001), and shorter time between the onset of symptoms and the need for hospitalization (7 [2-9] vs. 10 [6-12] days; p=0.039). CONCLUSION Long-term oxygen therapy is an effective strategy for reducing hospitalization time in COVID-19 patients, regardless of gravity. Additionally, more obese patients with persistence of respiratory symptoms, faster disease evolution, and more days of invasive mechanical ventilation needed to maintain the long-term oxygen therapy longer.
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Affiliation(s)
| | - Letícia Yumi Ishimoto
- São Paulo State University (UNESP), Medical School, Distrito de Rubião Junior s/n – Botucatu (SP), Brazil
| | | | | | | | - Camila Aparecida Colombo
- São Paulo State University (UNESP), Medical School, Distrito de Rubião Junior s/n – Botucatu (SP), Brazil
| | - Edris Guardiano Savadkouhi
- São Paulo State University (UNESP), Medical School, Distrito de Rubião Junior s/n – Botucatu (SP), Brazil
| | | | - Suzana Erico Tanni
- São Paulo State University (UNESP), Medical School, Distrito de Rubião Junior s/n – Botucatu (SP), Brazil
| | - Robson Prudente
- São Paulo State University (UNESP), Medical School, Distrito de Rubião Junior s/n – Botucatu (SP), Brazil
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2
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Partial update of the German S3 Guideline Sleep-Related Breathing Disorders in Adults. SOMNOLOGIE 2022. [DOI: 10.1007/s11818-022-00349-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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3
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Raphelson JR, Schmickl CN, Sonners C, Kreitinger K, Grunvald E, Horgan S, Malhotra A. Obesity Hypoventilation Syndrome and Postsurgical Outcomes in a Bariatric Surgery Cohort. Obes Surg 2022; 32:1-7. [PMID: 35538187 PMCID: PMC9276616 DOI: 10.1007/s11695-022-06073-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 04/13/2022] [Accepted: 04/20/2022] [Indexed: 12/04/2022]
Abstract
Purpose Patients with obesity and elevated serum bicarbonate suggesting obesity hypoventilation syndrome (OHS) undergoing bariatric surgery may represent a unique subgroup. Information regarding surgical outcomes in this population remains limited. We sought to test the hypothesis that an elevated bicarbonate would be an important predictor of perioperative complications (i.e., length of hospital stay) and postsurgical outcomes (i.e., weight loss at 1 year). Materials and Methods Consecutive patients undergoing bariatric surgery between January 2015 and December 2018 were included. Patients with a preoperative serum bicarbonate ≥ 27 mEq/L were classified as suspected OHS. Results Of 297 patients, the prevalence of suspected OHS based on an elevated bicarbonate was 19.5% (95% CI: 15.3 to 24.6%). Length of hospital stay was similar in the suspected OHS and non-OHS control group (1.50 vs 1.49 days, P = 0.98). The achieved weight loss from peak preoperative weight to 1 year post-surgery was less in the suspected OHS vs the control group (4.2% [95% CI 1.6 to 6.8]; P = 0.002). Conclusion Patients with serum bicarbonate ≥ 27 mEq/L as a surrogate marker for OHS experienced weight loss that was significantly less than their normal serum bicarbonate counterparts, but still achieved weight loss deemed clinically important by current guidelines. We observed no significant difference in length of hospital stay at time of surgery. Graphical abstract ![]()
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Affiliation(s)
- Janna R Raphelson
- Division of Internal Medicine, UC San Diego Health, San Diego, CA, 92109, USA.
| | - Christopher N Schmickl
- Division of Pulmonary, Critical Care, & Sleep Medicine, UC San Diego Health, San Diego, CA, 92109, USA
| | - Christine Sonners
- Division of Internal Medicine, UC San Diego Health, San Diego, CA, 92109, USA
| | - Kimberly Kreitinger
- Division of Internal Medicine, UC San Diego Health, San Diego, CA, 92109, USA
| | - Eduardo Grunvald
- Division of General Internal Medicine, UC San Diego Health, San Diego, CA, 92109, USA.,Bariatric and Metabolic Institute, UC San Diego Health, San Diego, CA, 92109, USA
| | - Santiago Horgan
- Bariatric and Metabolic Institute, UC San Diego Health, San Diego, CA, 92109, USA.,Department of Surgery, UC San Diego Health, San Diego, CA, 92109, USA
| | - Atul Malhotra
- Division of Pulmonary, Critical Care, & Sleep Medicine, UC San Diego Health, San Diego, CA, 92109, USA
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4
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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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5
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Masa JF, Benítez ID, Javaheri S, Mogollon MV, Sánchez-Quiroga MÁ, Terreros FJGD, Corral J, Gallego R, Romero A, Caballero-Eraso C, Ordax-Carbajo E, Gomez-Garcia T, González M, López-Martín S, Marin JM, Martí S, Díaz-Cambriles T, Chiner E, Egea C, Barca J, Barbé F, Mokhlesi B. Risk factors associated with pulmonary hypertension in obesity hypoventilation syndrome. J Clin Sleep Med 2021; 18:983-992. [PMID: 34755598 DOI: 10.5664/jcsm.9760] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES Pulmonary hypertension (PH) is prevalent in obesity hypoventilation syndrome (OHS). However, there is a paucity of data assessing pathogenic factors associated with PH. Our objective is to assess risk factors that may be involved in the pathogenesis of PH in untreated OHS. METHODS In a post-hoc analysis of the Pickwick trial, we performed a bivariate analysis of baseline characteristics between patients with and without PH. Variables with a p value ≤0.10 were defined as potential risk factors and were grouped by theoretical pathogenic mechanisms in several adjusted models. Similar analysis was carried out for the two OHS phenotypes, with and without severe concomitant obstructive sleep apnea (OSA). RESULTS Of 246 patients with OHS, 122 (50%) had echocardiographic evidence of PH defined as systolic pulmonary artery pressure ≥40 mmHg. Lower levels of awake PaO2 and higher body mass index (BMI) were independent risk factors in the multivariate model, with a negative and positive adjusted linear association, respectively (adjusted odds ratio 0.96; 95% CI 0.93 to 0.98; p = 0.003 for PaO2, and 1.07; 95% CI 1.03 to 1.12; p = 0.001 for BMI). In separate analyses, BMI and PaO2 were independent risk factors in the severe OSA phenotype, whereas BMI and peak in-flow velocity in early (E)/late diastole (A) ratio were independent risk factors in the non-severe OSA phenotype. CONCLUSIONS This study identifies obesity per se as a major independent risk factor for PH, regardless of OHS phenotype. Therapeutic interventions targeting weight loss may play a critical role in improving PH in this patient population. CLINICAL TRIALS REGISTRATION Registry: Clinicaltrial.gov; Identifier: 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)
| | - Iván D Benítez
- CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain.,Institut de Recerca Biomédica de Lleida (IRBLLEIDA), Lleida, Spain
| | - Shahrokh Javaheri
- Division of Pulmonary and Sleep Medicine, Bethesda North Hospital, Cincinnati, Ohio
| | | | - Maria Á Sánchez-Quiroga
- CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain.,Instituto Universitario de Investigación Biosanitaria de Extremadura (INUBE).,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)
| | - 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)
| | - Rocio Gallego
- Respiratory Department, San Pedro de Alcántara Hospital, Cáceres, Spain.,CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain.,Instituto Universitario de Investigación Biosanitaria de Extremadura (INUBE)
| | - 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
| | - 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).,Nursing Department, Extremadura University, Cáceres, Spain
| | - Ferrán Barbé
- CIBER de enfermedades respiratorias (CIBERES), Madrid, Spain.,Institut de Recerca Biomédica de Lleida (IRBLLEIDA), Lleida, Spain
| | - Babak Mokhlesi
- Medicine/Pulmonary and Critical Care, University of Chicago, IL
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6
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Dougherty M, Lomiguen CM, Chin J, McElroy PK. Obesity Hypoventilation Syndrome-Related Challenges in Acute Respiratory Failure. Cureus 2021; 13:e18066. [PMID: 34692288 PMCID: PMC8523440 DOI: 10.7759/cureus.18066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 09/17/2021] [Indexed: 11/05/2022] Open
Abstract
Obesity hypoventilation syndrome (OHS) is a condition commonly found in severely obese patients in which they fail to breathe deeply or rapidly enough to offset the body's need for oxygen consumption and carbon dioxide release. This report presents a case of a 49-year-old super-super-morbid obese female with a body mass index (BMI) of 90 kilogram per meter squared (kg/m²), chronic obstructive pulmonary disease (COPD), and end-stage cor pulmonale, who was brought to the emergency department for altered mental status and requiring emergent airway due to respiratory failure secondary to OHS. The continued increase in rates of obesity worldwide, especially in those with BMI ≥ 50 kg/m², may lead to an increase in the incidence of OHS. With comorbidities secondary to obesity and associated complexity, this medically challenging case emphasizes the need for refined management strategies in caring for OHS in super-super-morbidly obese patients.
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Affiliation(s)
- Michael Dougherty
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, USA
| | - Christine M Lomiguen
- Department of Medical Education, Lake Erie College of Osteopathic Medicine, Erie, USA.,Department of Family Medicine, Millcreek Community Hospital, Erie, USA
| | - Justin Chin
- Department of Medical Education, Lake Erie College of Osteopathic Medicine, Erie, USA.,Department of Family Medicine, LifeLong Medical Care, Richmond, USA
| | - Philip K McElroy
- Department of Anesthesiology, Thomas Jefferson University Hospital, Philadelphia, USA
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7
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Residual hypoxemia in obesity-hypoventilation syndrome: quantification of the ventilation/perfusion imbalance. Sleep Breath 2021; 26:1287-1288. [PMID: 34514514 DOI: 10.1007/s11325-021-02484-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Revised: 08/22/2021] [Accepted: 08/27/2021] [Indexed: 10/20/2022]
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8
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Janssens JP, Michel F, Schwarz EI, Prella M, Bloch K, Adler D, Brill AK, Geenens A, Karrer W, Ogna A, Ott S, Rüdiger J, Schoch OD, Soler M, Strobel W, Uldry C, Gex G. Long-Term Mechanical Ventilation: Recommendations of the Swiss Society of Pulmonology. Respiration 2020; 99:1-36. [PMID: 33302274 DOI: 10.1159/000510086] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Accepted: 07/09/2020] [Indexed: 12/12/2022] Open
Abstract
Long-term mechanical ventilation is a well-established treatment for chronic hypercapnic respiratory failure (CHRF). It is aimed at improving CHRF-related symptoms, health-related quality of life, survival, and decreasing hospital admissions. In Switzerland, long-term mechanical ventilation has been increasingly used since the 1980s in hospital and home care settings. Over the years, its application has considerably expanded with accumulating evidence of beneficial effects in a broad range of conditions associated with CHRF. Most frequent indications for long-term mechanical ventilation are chronic obstructive pulmonary disease, obesity hypoventilation syndrome, neuromuscular and chest wall diseases. In the current consensus document, the Special Interest Group of the Swiss Society of Pulmonology reviews the most recent scientific literature on long-term mechanical ventilation and provides recommendations adapted to the particular setting of the Swiss healthcare system with a focus on the practice of non-invasive and invasive home ventilation in adults.
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Affiliation(s)
- Jean-Paul Janssens
- Division of Pulmonary Diseases, Geneva University Hospitals, Geneva, Switzerland,
| | - Franz Michel
- Klinik für Neurorehabilitation und Paraplegiologie, Basel, Switzerland
| | - Esther Irene Schwarz
- Department of Pulmonology and Sleep Disorders Centre, University Hospital of Zurich, Zurich, Switzerland
| | - Maura Prella
- Division of Pulmonary Diseases, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Konrad Bloch
- Department of Pulmonology and Sleep Disorders Centre, University Hospital of Zurich, Zurich, Switzerland
| | - Dan Adler
- Division of Pulmonary Diseases, Geneva University Hospitals, Geneva, Switzerland
| | | | - Aurore Geenens
- Pulmonary League of the Canton of Vaud, Lausanne, Switzerland
| | | | - Adam Ogna
- Respiratory Medicine Service, Locarno Regional Hospital, Locarno, Switzerland
| | - Sebastien Ott
- Universitätsklinik für Pneumologie, Universitätsspital (Inselspital) und Universität, Bern, Switzerland
- Division of Pulmonary Diseases, St. Claraspital, Basel, Switzerland
| | - Jochen Rüdiger
- Division of Pulmonary and Sleep Medicine, Medizin Stollturm, Münchenstein, Switzerland
| | - Otto D Schoch
- Division of Pulmonary Diseases, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Markus Soler
- Division of Pulmonary Diseases, St. Claraspital, Basel, Switzerland
| | - Werner Strobel
- Division of Pulmonary Diseases, Universitätsspital Basel, Basel, Switzerland
| | - Christophe Uldry
- Division of Pulmonary Diseases and Pulmonary Rehabilitation Center, Rolle Hospital, Rolle, Switzerland
| | - Grégoire Gex
- Division of Pulmonary Diseases, Geneva University Hospitals, Geneva, Switzerland
- Division of Pulmonary Diseases, Hôpital du Valais, Sion, Switzerland
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9
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Stuck BA, Arzt M, Fietze I, Galetke W, Hein H, Heiser C, Herkenrath SD, Hofauer B, Maurer JT, Mayer G, Orth M, Penzel T, Randerath W, Sommer JU, Steffen A, Wiater A. Teil-Aktualisierung S3-Leitlinie Schlafbezogene Atmungsstörungen bei Erwachsenen. SOMNOLOGIE 2020. [DOI: 10.1007/s11818-020-00257-6] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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10
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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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11
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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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12
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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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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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Afraz S, Dang JT, Modasi A, Switzer N, Birch DW, Karmali S. Bariatric surgery outcomes in oxygen-dependent patients: analysis of the MBSAQIP database. Surg Obes Relat Dis 2019; 15:1571-1580. [DOI: 10.1016/j.soard.2019.06.030] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 05/28/2019] [Accepted: 06/21/2019] [Indexed: 12/21/2022]
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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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Sunwoo BY. Obesity Hypoventilation: Pathophysiology, Diagnosis, and Treatment. CURRENT PULMONOLOGY REPORTS 2019. [DOI: 10.1007/s13665-019-0223-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Athayde RABD, Oliveira Filho JRBD, Lorenzi Filho G, Genta PR. Obesity hypoventilation syndrome: a current review. ACTA ACUST UNITED AC 2019; 44:510-518. [PMID: 30726328 PMCID: PMC6459748 DOI: 10.1590/s1806-37562017000000332] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 02/11/2018] [Indexed: 02/06/2023]
Abstract
Obesity hypoventilation syndrome (OHS) is defined as the presence of obesity (body mass index ≥ 30 kg/m²) and daytime arterial hypercapnia (PaCO2 ≥ 45 mmHg) in the absence of other causes of hypoventilation. OHS is often overlooked and confused with other conditions associated with hypoventilation, particularly COPD. The recognition of OHS is important because of its high prevalence and the fact that, if left untreated, it is associated with high morbidity and mortality. In the present review, we address recent advances in the pathophysiology and management of OHS, the usefulness of determination of venous bicarbonate in screening for OHS, and diagnostic criteria for OHS that eliminate the need for polysomnography. In addition, we review advances in the treatment of OHS, including behavioral measures, and recent studies comparing the efficacy of continuous positive airway pressure with that of noninvasive ventilation.
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Affiliation(s)
- Rodolfo Augusto Bacelar de Athayde
- . Serviço de Pneumologia, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil.,. Laboratório do Sono, Disciplina de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | | | - Geraldo Lorenzi Filho
- . Laboratório do Sono, Disciplina de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | - Pedro Rodrigues Genta
- . Laboratório do Sono, Disciplina de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
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Bouloukaki I, Mermigkis C, Michelakis S, Moniaki V, Mauroudi E, Tzanakis N, Schiza SE. The Association Between Adherence to Positive Airway Pressure Therapy and Long-Term Outcomes in Patients With Obesity Hypoventilation Syndrome: A Prospective Observational Study. J Clin Sleep Med 2018; 14:1539-1550. [PMID: 30176976 DOI: 10.5664/jcsm.7332] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 06/20/2018] [Indexed: 11/13/2022]
Abstract
STUDY OBJECTIVES To assess the role of different levels of adherence and long-term effects of positive airway pressure (PAP) therapy on gas exchange, sleepiness, quality of life, depressive symptoms, and all-cause mortality in patients with obesity hypoventilation syndrome (OHS). METHODS A total of 252 patients with newly diagnosed OHS were followed up for a minimum of 2 years after PAP initiation. PAP adherence (h/night) was monitored. Arterial blood gas samples were taken with patients being alert for more than 4 hours after morning awakening. Subjective daytime sleepiness (Epworth Sleepiness Scale [ESS]), quality of life (Short Form 36 [SF-36]) and patient's depressive symptoms (Beck Depression Inventory [BDI]) were assessed before and at the end of the follow-up period, along with all-cause mortality. RESULTS At the end of the follow-up period (median duration [25th-75th percentile], 30 [24-52] months), PaO2 increased from baseline (72.7 ± 10.3 versus 63.2 ± 10.6, P < .001) and both PaCO2 and HCO3- decreased (43.0 [39.2-45.0] versus 50.0 [46.7-55.4] and 27.5 ± 3.2 versus 31.4 ± 4.2, respectively, P < .001). In addition, PAP therapy significantly improved ESS (7 [4-9] versus 14 [11-16], P < .001), BDI (8.8 ± 4.9 versus 15.5 ± 7.3, P < .001) and SF-36 (82 [78-87] versus 74 [67-79], P < .001) scores. Over the follow-up period 11 patients died. Patients who used PAP for > 6 h/night had significant improvements (P < .05) in blood gases and SF-36 scores than less adherent patients. CONCLUSIONS Increased hours of use and long-term therapy with PAP are effective in the treatment of patients with OHS. Clinicians should encourage adherence to PAP therapy in order to provide a significant improvement in clinical status and gas exchange in these patients. COMMENTARY A commenary on this article appears in this issue on page 1455. CLINICAL TRIAL REGISTRATION Title: PAP Therapy in Patients With Obesity Hypoventilation Syndrome, Registry: ClinicalTrials.gov, Identifier: NCT03449641, URL: https://clinicaltrials.gov/ct2/show/NCT03449641.
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Affiliation(s)
- Izolde Bouloukaki
- Sleep Disorders Center, Department of Thoracic Medicine, University of Crete, Heraklion, Greece
| | - Charalampos Mermigkis
- Sleep Disorders Center, Department of Thoracic Medicine, University of Crete, Heraklion, Greece
| | - Stylianos Michelakis
- Sleep Disorders Center, Department of Thoracic Medicine, University of Crete, Heraklion, Greece
| | - Violeta Moniaki
- Sleep Disorders Center, Department of Thoracic Medicine, University of Crete, Heraklion, Greece
| | - Eleni Mauroudi
- Sleep Disorders Center, Department of Thoracic Medicine, University of Crete, Heraklion, Greece
| | - Nikolaos Tzanakis
- Sleep Disorders Center, Department of Thoracic Medicine, University of Crete, Heraklion, Greece
| | - Sophia E Schiza
- Sleep Disorders Center, Department of Thoracic Medicine, University of Crete, Heraklion, Greece
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Sleep-disordered breathing, circulating exosomes, and insulin sensitivity in adipocytes. Int J Obes (Lond) 2018; 42:1127-1139. [PMID: 29892042 PMCID: PMC6195831 DOI: 10.1038/s41366-018-0099-9] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Revised: 02/20/2018] [Accepted: 03/12/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Sleep-disordered-breathing (SDB), which is characterized by chronic intermittent hypoxia (IH) and sleep fragmentation (SF), is a prevalent condition that promotes metabolic dysfunction, particularly among patients suffering from obstructive hypoventilation syndrome (OHS). Exosomes are generated ubiquitously, are readily present in the circulation, and their cargo may exert substantial functional cellular alterations in both physiological and pathological conditions. However, the effects of plasma exosomes on adipocyte metabolism in patients with OHS or in mice subjected to IH or SF mimicking SDB are unclear. METHODS Exosomes from fasting morning plasma samples from obese adults with polysomnographically-confirmed OSA before and after 3 months of adherent CPAP therapy were assayed. In addition, C57BL/6 mice were randomly assigned to (1) sleep control (SC), (2) sleep fragmentation (SF), and (3) intermittent hypoxia (HI) for 6 weeks, and plasma exosomes were isolated. Equivalent exosome amounts were added to differentiated adipocytes in culture, after which insulin sensitivity was assessed using 0 nM and 5 nM insulin-induced pAKT/AKT expression changes by western blotting. RESULTS When plasma exosomes were co-cultured and internalized by human naive adipocytes, significant reductions emerged in Akt phosphorylation responses to insulin when compared to exosomes obtained after 24 months of adherent CPAP treatment (n = 24; p < 0.001), while no such changes occur in untreated patients (n = 8). In addition, OHS exosomes induced significant increases in adipocyte lipolysis that were attenuated after CPAP, but did not alter pre-adipocyte differentiation. Similarly, exosomes from SF- and IH-exposed mice induced attenuated p-AKT/total AKT responses to exogenous insulin and increased glycerol content in naive murine adipocytes, without altering pre-adipocyte differentiation. CONCLUSIONS Using in vitro adipocyte-based functional reporter assays, alterations in plasma exosomal cargo occur in SDB, and appear to contribute to adipocyte metabolic dysfunction. Further exploration of exosomal miRNA signatures in either human subjects or animal models and their putative organ and cell targets appears warranted.
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Melani AS, Sestini P, Rottoli P. Home oxygen therapy: re-thinking the role of devices. Expert Rev Clin Pharmacol 2018; 11:279-289. [PMID: 29272974 DOI: 10.1080/17512433.2018.1421457] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION A range of devices are available for delivering and monitoring home oxygen therapy (HOT). Guidelines do not give indications for the choice of the delivery device but recommend the use of an ambulatory system in subjects on HOT whilst walking. Areas covered: We provide a clinical overview of HOT and review traditional and newer delivery and monitoring devices for HOT. Despite relevant technology advancements, clinicians, faced with many challenges when they prescribe oxygen therapy, often remain familiar to traditional devices and continuous flow delivery of oxygen. Some self-filling delivery-less devices could increase the users' level of independence with ecological advantage and, perhaps, reduced cost. Some newer portable oxygen concentrators are being available, but more work is needed to understand their performances in different diseases and clinical settings. Pulse oximetry has gained large diffusion worldwide and some models permit long-term monitoring. Some closed-loop portable monitoring devices are also able to adjust oxygen flow automatically in accordance with the different needs of everyday life. This might help to improve adherence and the practice of proper oxygen titration that has often been omitted because difficult to perform and time-consuming. Expert commentary: The prescribing physicians should know the characteristics of newer devices and use technological advancements to improve the practice of HOT.
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Affiliation(s)
- Andrea S Melani
- a Fisiopatologia e Riabilitazione Respiratoria, Dipartimento Vasi, Cuore e Torace, Policlinico Le Scotte , Azienda Ospedaliera Universitaria Senese , Siena , Italy
| | - Piersante Sestini
- b Clinica delle Malattie dell'Apparato Respiratorio, Dipartimento di Medicine Specialistica, Policlinico Le Scotte , Azienda Ospedaliera Universitaria Senese , Siena , Italy
| | - Paola Rottoli
- a Fisiopatologia e Riabilitazione Respiratoria, Dipartimento Vasi, Cuore e Torace, Policlinico Le Scotte , Azienda Ospedaliera Universitaria Senese , Siena , Italy.,b Clinica delle Malattie dell'Apparato Respiratorio, Dipartimento di Medicine Specialistica, Policlinico Le Scotte , Azienda Ospedaliera Universitaria Senese , Siena , Italy
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Corral J, Mogollon MV, Sánchez-Quiroga MÁ, Gómez de Terreros J, Romero A, Caballero C, Teran-Santos J, Alonso-Álvarez ML, Gómez-García T, González M, López-Martínez S, de Lucas P, Marin JM, Romero O, Díaz-Cambriles T, Chiner E, Egea C, Lang RM, Mokhlesi B, Masa JF. Echocardiographic changes with non-invasive ventilation and CPAP in obesity hypoventilation syndrome. Thorax 2017; 73:361-368. [DOI: 10.1136/thoraxjnl-2017-210642] [Citation(s) in RCA: 46] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 09/20/2017] [Accepted: 10/30/2017] [Indexed: 11/03/2022]
Abstract
RationaleDespite a significant association between obesity hypoventilation syndrome (OHS) and cardiac dysfunction, no randomised trials have assessed the impact of non-invasive ventilation (NIV) or CPAP on cardiac structure and function assessed by echocardiography.ObjectivesWe performed a secondary analysis of the data from the largest multicentre randomised controlled trial of OHS (Pickwick project, n=221) to determine the comparative efficacy of 2 months of NIV (n=71), CPAP (n=80) and lifestyle modification (control group, n=70) on structural and functional echocardiographic changes.MethodsConventional transthoracic two-dimensional and Doppler echocardiograms were obtained at baseline and after 2 months. Echocardiographers at each site were blinded to the treatment arms. Statistical analysis was performed using intention-to-treat analysis.ResultsAt baseline, 55% of patients had pulmonary hypertension and 51% had evidence of left ventricular hypertrophy. Treatment with NIV, but not CPAP, lowered systolic pulmonary artery pressure (−3.4 mm Hg, 95% CI −5.3 to –1.5; adjusted P=0.025 vs control and P=0.033 vs CPAP). The degree of improvement in systolic pulmonary artery pressure was greater in patients treated with NIV who had pulmonary hypertension at baseline (−6.4 mm Hg, 95% CI −9 to –3.8). Only NIV therapy decreased left ventricular hypertrophy with a significant reduction in left ventricular mass index (−5.7 g/m2; 95% CI −11.0 to –4.4). After adjusted analysis, NIV was superior to control group in improving left ventricular mass index (P=0.015). Only treatment with NIV led to a significant improvement in 6 min walk distance (32 m; 95% CI 19 to 46).ConclusionIn patients with OHS, medium-term treatment with NIV is more effective than CPAP and lifestyle modification in improving pulmonary hypertension, left ventricular hypertrophy and functional outcomes. Long-term studies are needed to confirm these results.Trial registration numberPre-results, NCT01405976 (https://clinicaltrials.gov/).
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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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