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Obesity Hypoventilation

Syndrome “OHS”
Abdul Alraiyes MD.

©2009 Alraiyes
Objectives

 To discuss the obesity hypoventilation and


hypercapnia
 Hypercapnia and periodic breathing
 Apnea / inter-apnea interval ratio
 PHOX2B and hypoventilation
 Manifestation and approach to diagnosis and
management of OHS

©2009 Alraiyes
Consult

 63 Y/O male with multiple medical problems admited with


CHF exacerbation and SOB
 the patient started on CPAP 7 cmH2O during this hospital
admission and his sleep and day time sleepiness improved.

©2009 Alraiyes
Sleep History
 the patient is a third shift worker for 10 years before he
retired 9 years ago
 and according to him he still having late phase of sleep
every night,
 Bed time: 1:30 am
 Sleep latency: 5 min
 Wake up at night: at 4 am for a bathroom use
 wake up time in am: 9:00am
 Naps: once a day at 5:00 pm for 1 hour
 ESS: 16/24
 Loud snoring
 witnessed sleep apneas
 Got worse over the 8 years with weight gain of 80 pounds.
 History of car accident 2 years secondary to sleepiness
while driving

©2009 Alraiyes
PMHx

 A.fib
 CAD
 CHF
 HTN
 DM
 COPD chronically on 3L oxygen; no PFTs in system
 OSA

©2009 Alraiyes
Medications
 ASA
 Carvedilol
 Lasix
 Glipizide
 NPH
 Lisinopril
 Clariitn
 Omeprazole
 Simvastatin
 Coumadin

©2009 Alraiyes
Physical Exam
V/S
T:96.6 F (35.9 C)
P: 70
R: 20
B/P: 101/57*
Pain: 0 - No pain
BMI: 43.6

 Morbid obese the patient is a mouth breather


 HEENT: retrognathia, with MAL III, very busy oropharynx anatomy, enlarged
uvula, tonsils #2 no nasal septal deviation or enlarged turbinates. neck
20.5 inches
 Chest: good air entry bil basal crackles
 CVS: S1+S2+SEM
 Abd: obese soft and lax no paradox abdominal breathing and scrotal
edema
 Ext: 2+ pitting edema with.

©2009 Alraiyes
Labs
ABG
13.3
5.9 \____/ 143 PH: 7.35
/ 42 \ PaCO2: 64.3
PaO2: 87
HCO3: 37
138 98 47
___|___|____/ 110
4.8 | 38 | 1.4 \
HCO3

Jun Aug Jan Mar Jul Dec Apr Mar Jul Sep
2003 2004 2005 2005 2006 2006 2008 2009 2009 2009
24 23 25 26 30 28 30 33 32 37

©2009 Alraiyes
2D-Echo

 7/09-preserved EF,
 moderate to severe LVH,
 LA and RA mod dilated, trace MR, mild TR,
 no AV stenosis;
 RV pressures are normal

©2009 Alraiyes
Summary

 63 Y/O Male with PMHx of DM, HTN, CHF, A-fib, COPD.


 Admited 2nd to CHF exacerbation and fluid over load treated
with diuretics and assessed by Pulmonary team started on
CPAP 7 cm H2O
 Pt symptoms and sleep quality improved.

©2009 Alraiyes
OHS

©2009 Alraiyes
OHS
Obesity hypoventilation syndrome (OHS) is characterized by obesity,
daytime hypercapnia, and sleep-disordered breathing in the absence
of significant lung or respiratory muscle disease.

©www.endotext.org

©2009 Alraiyes
OHS
exclusion of:

•severe obstructive or restrictive pulmonary disease


•Significant kyphoscoliosis
•severe hypothyroidism
•neuromuscular diseases.

Babak Mokhlesi, Meir H. Kryger and Ronald R. Grunstein Assessment and Management of Patients with Obesity
Hypoventilation Syndrome The Proceedings of the American Thoracic Society 5:218-225 (2008)

©2009 Alraiyes
OHS Epidemiology

Babak Mokhlesi, Meir H. Kryger and Ronald R. Grunstein Assessment and Management of Patients with Obesity
Hypoventilation Syndrome The Proceedings of the American Thoracic Society 5:218-225 (2008)
Tsuneto Akashiba , Toshiki Akahoshi , Seiji Kawahara, Akihito Uematsu, Kazuhito Katsura , Shigeru Sakurai , Akira
Murata 3, Hiroki Sakakibara 4,Kazuo Chin 5, Wataru Hida 6 and Hiroshi Nakamura 7 Clinical Characteristics of Obesity-
hypoventilation Syndrome in Japan: a Multi-center Study internal medicine Vol. 45 (2006) , No. 20 pp.1121-1125

©2009 Alraiyes
OHS Epidemiology

Babak Mokhlesi, Meir H. Kryger and Ronald R. Grunstein Assessment and Management of Patients with Obesity
Hypoventilation Syndrome The Proceedings of the American Thoracic Society 5:218-225 (2008)
Tsuneto Akashiba , Toshiki Akahoshi , Seiji Kawahara, Akihito Uematsu, Kazuhito Katsura , Shigeru Sakurai , Akira
Murata 3, Hiroki Sakakibara 4,Kazuo Chin 5, Wataru Hida 6 and Hiroshi Nakamura 7 Clinical Characteristics of Obesity-
hypoventilation Syndrome in Japan: a Multi-center Study internal medicine Vol. 45 (2006) , No. 20 pp.1121-1125

©2009 Alraiyes
OHS Epidemiology

Babak Mokhlesi, Meir H. Kryger and Ronald R. Grunstein Assessment and Management of Patients with Obesity
Hypoventilation Syndrome The Proceedings of the American Thoracic Society 5:218-225 (2008)

©2009 Alraiyes
OHS Diagnosis:
Hypoventilation
High High
Obesity BMI > 30 Hypoxia
HCO3 PaCO2
Daytime sleepiness

Pulse CBC
ABG CXR PFT
OX TSH

Babak Mokhlesi, Meir H. Kryger and Ronald R. Grunstein Assessment and Management of Patients with Obesity
Hypoventilation Syndrome The Proceedings of the American Thoracic Society 5:218-225 (2008)

©2009 Alraiyes
OHS Pathophysiology

Babak Mokhlesi, Meir H. Kryger and Ronald R. Grunstein Assessment and Management of Patients with Obesity
Hypoventilation Syndrome The Proceedings of the American Thoracic Society 5:218-225 (2008)

©2009 Alraiyes
OHS Pathophysiology

Babak Mokhlesi, Meir H. Kryger and Ronald R. Grunstein Assessment and Management of Patients with Obesity
Hypoventilation Syndrome The Proceedings of the American Thoracic Society 5:218-225 (2008)

©2009 Alraiyes
OHS pathophysiology

I. Rubinstein, MD; N. Zamel, MD; L. DuBarry, RPT; and V. Hoffstein, MD Airflow Limitation in Morbidly Obese, Nonsmoking
Men Annals of internal medicine, 1990 - Am Coll Physicians

©2009 Alraiyes
OHS Pathophysiology

I. Rubinstein, MD; N. Zamel, MD; L. DuBarry, RPT; and V. Hoffstein, MD Airflow Limitation in Morbidly Obese, Nonsmoking
Men Annals of internal medicine, 1990 - Am Coll Physicians

©2009 Alraiyes
OHS Pathophysiology

 The control of the inter-apnea duration relative to the


duration of the preceding apnea is an important component
for the development of chronic hypercapnia in obstructive
sleep apnea

Indu Ayappa, Kenneth I. Berger, Robert G. Norman, Beno W. Oppenheimer, David M. Rapoport, and Roberta M.
Goldring Hypercapnia and Ventilatory Periodicity in Obstructive Sleep Apnea Syndrome Am J Respir Crit Care Med
Vol 166. pp 1112–1115, 2002

©2009 Alraiyes
Pathophysiology

Indu Ayappa, Kenneth I. Berger, Robert G. Norman, Beno W. Oppenheimer, David M. Rapoport, and Roberta M.
Goldring Hypercapnia and Ventilatory Periodicity in Obstructive Sleep Apnea Syndrome Am J Respir Crit Care Med
Vol 166. pp 1112–1115, 2002

©2009 Alraiyes
Pathophysiology

 The average apnea / inter-apnea


duration ratio was directly related
to the chronic awake PCO2

Indu Ayappa, Kenneth I. Berger, Robert G. Norman, Beno W. Oppenheimer, David M. Rapoport, and Roberta M.
Goldring Hypercapnia and Ventilatory Periodicity in Obstructive Sleep Apnea Syndrome Am J Respir Crit Care Med
Vol 166. pp 1112–1115, 2002

©2009 Alraiyes
Pathophysiology

Indu Ayappa, Kenneth I. Berger, Robert G. Norman, Beno W. Oppenheimer, David M. Rapoport, and Roberta M.
Goldring Hypercapnia and Ventilatory Periodicity in Obstructive Sleep Apnea Syndrome Am J Respir Crit Care Med
Vol 166. pp 1112–1115, 2002

©2009 Alraiyes
Pathophysiology

Babak Mokhlesi, Meir H. Kryger and Ronald R. Grunstein Assessment and Management of Patients with Obesity
Hypoventilation Syndrome The Proceedings of the American Thoracic Society 5:218-225 (2008)

©2009 Alraiyes
Pathophysiology

Babak Mokhlesi, Meir H. Kryger and Ronald R. Grunstein Assessment and Management of Patients with Obesity
Hypoventilation Syndrome The Proceedings of the American Thoracic Society 5:218-225 (2008)

©2009 Alraiyes
Pathophysiology

Babak Mokhlesi, Meir H. Kryger and Ronald R. Grunstein Assessment and Management of Patients with Obesity
Hypoventilation Syndrome The Proceedings of the American Thoracic Society 5:218-225 (2008)

©2009 Alraiyes
Pathophysiology

Babak Mokhlesi, Meir H. Kryger and Ronald R. Grunstein Assessment and Management of Patients with Obesity
Hypoventilation Syndrome The Proceedings of the American Thoracic Society 5:218-225 (2008)

©2009 Alraiyes
Mathematical model of Periodic
breathing

A temporal V˙/Q˙ mismatch periodic


breathing pattern is responsible for
the hypercapnia

Bohr equation:
PaCO2= constant x CO2 production/ventilation

D. M. Rapoport, R. G. Norman and R. M. Goldring CO2 homeostasis during periodic breathing: predictions
from a computer model J. Appl. Physiol. 75(5): 2302- 2309, 1993.

©2009 Alraiyes
Mathematical model of Periodic
breathing

D. M. Rapoport, R. G. Norman and R. M. Goldring CO2 homeostasis during periodic breathing: predictions
from a computer model J. Appl. Physiol. 75(5): 2302- 2309, 1993.
©2009 Alraiyes
Mathematical model of Periodic
breathing

D. M. Rapoport, R. G. Norman and R. M. Goldring CO2 homeostasis during periodic breathing: predictions
from a computer model J. Appl. Physiol. 75(5): 2302- 2309, 1993.

©2009 Alraiyes
Mathematical model of Periodic
breathing

D. M. Rapoport, R. G. Norman and R. M. Goldring CO2 homeostasis during periodic breathing: predictions
from a computer model J. Appl. Physiol. 75(5): 2302- 2309, 1993.
©2009 Alraiyes
Apnea/inter-apnea ratio and
hypercapnia

exclusion of:

1) Periodic breathing provides a mechanism for acute hypercapnia in OSA,


2) Acute hypercapnia during periodic breathing may occur without a decrease
in average Vmin, mainly secondary to temporal V˙/Q˙ mismatch
3) Compensation for CO2 accumulation during apnea/hypopnea may be
limited by the duration of the interevent interval.

Kenneth I. Berger, Indu Ayappa, I. Barry Sorkin, Robert G. Norman, CO2 homeostasis during periodic
breathing in obstructive sleep apnea J. Appl. Physiol. 88: 257–264, 2000.

©2009 Alraiyes
Apnea/inter-apnea ratio and
hypercapnia

Kenneth I. Berger, Indu Ayappa, I. Barry Sorkin, Robert G. Norman, CO2 homeostasis during periodic
breathing in obstructive sleep apnea J. Appl. Physiol. 88: 257–264, 2000.

©2009 Alraiyes
Apnea/inter-apnea ratio and
hypercapnia

Kenneth I. Berger, Indu Ayappa, I. Barry Sorkin, Robert G. Norman, CO2 homeostasis during periodic
breathing in obstructive sleep apnea J. Appl. Physiol. 88: 257–264, 2000.

©2009 Alraiyes
Kenneth I. Berger, Indu Ayappa, I. Barry Sorkin, Robert G. Norman, CO2 homeostasis during periodic
breathing in obstructive sleep apnea J. Appl. Physiol. 88: 257–264, 2000.
©2009 Alraiyes
Apnea/inter-apnea ratio and
hypercapnia

Kenneth I. Berger, Indu Ayappa, I. Barry Sorkin, Robert G. Norman, CO2 homeostasis during periodic
breathing in obstructive sleep apnea J. Appl. Physiol. 88: 257–264, 2000.

©2009 Alraiyes
Apnea/inter-apnea ratio and
hypercapnia

Kenneth I. Berger, Indu Ayappa, I. Barry Sorkin, Robert G. Norman, CO2 homeostasis during periodic
breathing in obstructive sleep apnea J. Appl. Physiol. 88: 257–264, 2000.

©2009 Alraiyes
Apnea/inter-apnea ratio and
hypercapnia

effects of the event-tointerevent duration ratio on cycle CO2 balance:

1) When the event duration was short relative to the interevent duration (3:1),
the cycle CO2 balance varied around zero and averaged 24 ml.

2) cycles with ratios 3:1 or more accounted for 80% of the total positive CO2
balance during the period of sleep.

Kenneth I. Berger, Indu Ayappa, I. Barry Sorkin, Robert G. Norman, CO2 homeostasis during periodic
breathing in obstructive sleep apnea J. Appl. Physiol. 88: 257–264, 2000.

©2009 Alraiyes
Hypoventilation and PhOX2B

Ve´ ronique Dubreuil, Ne´ lina Ramanantsoa, Delphine Trochet, Vanessa Vaubourg, Jeanne Amie, Jorge Gallego A human
mutation in Phox2b causes lack of CO2 chemosensitivity, fatal central apnea, and specific loss of parafacial neurons 2008
Jan 22;105(3):1067-72
Debra E. Weese-Mayer , Casey M. Rand , Elizabeth M. Berry-Kravis, Larry J. Jennings , Darius A. Loghmanee , Pallavi P.
Patwari , Isabella Ceccherini Congenital central hypoventilation syndrome from past to future: Model for translational and
transitional autonomic medicine Pediatr Pulmonol. 2009 Jun;44(6):521-35

©2009 Alraiyes
Hypoventilation and PhOX2B

Ve´ ronique Dubreuil, Ne´ lina Ramanantsoa, Delphine Trochet, Vanessa Vaubourg, Jeanne Amie, Jorge Gallego A human
mutation in Phox2b causes lack of CO2 chemosensitivity, fatal central apnea, and specific loss of parafacial neurons 2008
Jan 22;105(3):1067-72
Debra E. Weese-Mayer , Casey M. Rand , Elizabeth M. Berry-Kravis, Larry J. Jennings , Darius A. Loghmanee , Pallavi P.
Patwari , Isabella Ceccherini Congenital central hypoventilation syndrome from past to future: Model for translational and
transitional autonomic medicine Pediatr Pulmonol. 2009 Jun;44(6):521-35

©2009 Alraiyes
OHS morbidities
•OHS patients has:

•congestive heart failure (odds ratio [OR], 9; 95% confidence interval


[95% CI], 2.3–35)
•angina pectoris (OR, 9; 95% CI, 1.4–57.1),
•cor pulmonale (OR, 9; 95% CI, 1.4–57.1)
•More hospitalization compared with patients with a similar degree of
obesity but without hypoventilation
•higher rates of admission to the intensive care unit .
• Higher rates of invasive mechanical ventilation
•hypertension (OR, 3.8; 95% CI, 1.5–9.8)
•diabetes mellitus (OR,17.2; 95% CI, 7.3–40.7)
•hypothyroidism (OR, 6.5; 95% CI, 2.4–17.5)
•PAH compared with eucapneic patients w

Babak Mokhlesi, Meir H. Kryger and Ronald R. Grunstein Assessment and Management of Patients with Obesity
Hypoventilation Syndrome The Proceedings of the American Thoracic Society 5:218-225 (2008)

©2009 Alraiyes
OHS mortality

Babak Mokhlesi, Meir H. Kryger and Ronald R. Grunstein Assessment and Management of Patients with Obesity
Hypoventilation Syndrome The Proceedings of the American Thoracic Society 5:218-225 (2008)

©2009 Alraiyes
OHS Treatment: O2 therapy

•Half of the patient with OHS require supplemental nocturnal


oxygen in addition to some form of PAP therapy.
•The need for nocturnal and daytime oxygen therapy decreases
significantly in patients adherent with PAP therapy

Babak Mokhlesi, Meir H. Kryger and Ronald R. Grunstein Assessment and Management of Patients with Obesity
Hypoventilation Syndrome The Proceedings of the American Thoracic Society 5:218-225 (2008)

©2009 Alraiyes
OHS Treatment: Weight loss
•In general weight loss results in:
• Improvement in sleep-disordered breathing
•Reduction in awake respiratory failure,
•Improvement in lung function in patients with OHS
•That can be achieved with bariatric surgery
•On the other hand OHS patients are at increased risk of death related to gastric
bypass surgery, in part because of the increased risk of postoperative respiratory
failure and the development of pulmonary embolism.
•Pre-op assessment and treatment with CPAP before surgery and directly after
extubation reduce the post op respiratory failure.

Babak Mokhlesi, Meir H. Kryger and Ronald R. Grunstein Assessment and Management of Patients with Obesity
Hypoventilation Syndrome The Proceedings of the American Thoracic Society 5:218-225 (2008)

©2009 Alraiyes
OHS Pharmacological treatment:

•Progesterone
•Almitrine
•Acetazolamide
•Leptin replacement

Babak Mokhlesi, Meir H. Kryger and Ronald R. Grunstein Assessment and Management of Patients with Obesity
Hypoventilation Syndrome The Proceedings of the American Thoracic Society 5:218-225 (2008)

©2009 Alraiyes
OHS Ventilation treatment:

•Ventilatory support via tracheostomy for obesity-related respiratory


failure has been used since the 1960s.

•NPPV using a face or, later, nasal mask was regularly used in OHS
from the late 1980s.

Babak Mokhlesi, Meir H. Kryger and Ronald R. Grunstein Assessment and Management of Patients with Obesity
Hypoventilation Syndrome The Proceedings of the American Thoracic Society 5:218-225 (2008)

©2009 Alraiyes
OHS Ventilation treatment:

Kenneth I. Berger, MD, FCCP; Indu Ayappa, PhD; Barbara Chatr-amontri, MD; Apurva Marfatia, MD; I. Barry Sorkin,
RRT; David M. Rapoport, MD; and Roberta M. Goldring, MD Obesity Hypoventilation Syndrome as a Spectrum of
Respiratory Disturbances During Sleep CHEST 2001; 120:1231–1238

©2009 Alraiyes
OHS Ventilation treatment:

Kenneth I. Berger, MD, FCCP; Indu Ayappa, PhD; Barbara Chatr-amontri, MD; Apurva Marfatia, MD; I. Barry Sorkin,
RRT; David M. Rapoport, MD; and Roberta M. Goldring, MD Obesity Hypoventilation Syndrome as a Spectrum of
Respiratory Disturbances During Sleep CHEST 2001; 120:1231–1238

©2009 Alraiyes
OHS Ventilation treatment: “in patient”

Hypoventilation
Obesity BMI > 30
Daytime sleepiness

Role out unstable


medical status

Role out
Contraindications
to NPPV

Babak Mokhlesi, Meir H. Kryger and Ronald R. Grunstein Assessment and Management of Patients with Obesity
Hypoventilation Syndrome The Proceedings of the American Thoracic Society 5:218-225 (2008)

©2009 Alraiyes
OHS Ventilation treatment: “in patient”

Babak Mokhlesi, Meir H. Kryger and Ronald R. Grunstein Assessment and Management of Patients with Obesity
Hypoventilation Syndrome The Proceedings of the American Thoracic Society 5:218-225 (2008)

©2009 Alraiyes
OHS Ventilation treatment: “in patient”

Babak Mokhlesi, Meir H. Kryger and Ronald R. Grunstein Assessment and Management of Patients with Obesity
Hypoventilation Syndrome The Proceedings of the American Thoracic Society 5:218-225 (2008)

©2009 Alraiyes
My patient

•Last moment consult


•PSG ordered
•Sent home on CPAP 7 cmH2O

Babak Mokhlesi, Meir H. Kryger and Ronald R. Grunstein Assessment and Management of Patients with Obesity
Hypoventilation Syndrome The Proceedings of the American Thoracic Society 5:218-225 (2008)

©2009 Alraiyes
OHS
Questions??

©2009 Alraiyes
OHS

Thank You

©2009 Alraiyes