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Severe obesity BMI > 30 kg/m2 and diurnal PaCO2 > 45 mmHg
In the absence of other known cause of hypoventilation
Adapted de Pépin, Borel, Tamisier, Lévy
OR 4.0
Adjusting for age sex BMI

Mortality is increased compared to “simple obesity” suggesting specific
cardiovascular morbidity
Nowbar. Am J Med 2004


Compared with eucapnic morbidly obese patients and
eucapnic patients with sleep-disordered breathing, patients
with OHS have increased health care expenses and are at
higher risk of developing serious cardiovascular disease
leading to early mortality.



Despite the significant morbidity and mortality associated
with this syndrome, diagnosis and institution of effective
treatment occur late in the course of the syndrome.

Mokhlesi B, Kryger MH, Grunstein RR. Assessment and management of
patients with obesity hypoventilation syndrome. Proc Am Thorac Soc. 2008


This is believed to be the ideal treatment for OHS.
 Respiratory insufficiency, pulmonary hypertension and sleep disorders

[Dixon JB 2012] can be reversed if patients achieve a normal
weight, although only a few maintain a significant weight reduction
for a long period.



Although bariatric surgery has been tested as an alternative
treatment for OSA patients with extreme obesity, there are still
some doubts about the benefit of this kind of therapy [Dixon JB
2012].



Less data are available in the case of OHS especially as regards
the long-term consequences. [Douglas C, 2012]



Moreover, bariatric surgery can be an alternative for only a
minority of OHS patients due to the morbidity and mortality
inherent in the surgical procedure itself
Behaviorally , diet and pharmacologically weight loss in OSA

Douglas C. OSA and Weight Loss: Review. Sleep Disord. 2012
Surgically induced weight loss in OSA
Surgical vs Conventional Therapy for Weight Loss Treatment of OSA
– BODY WEIGHT

Dixon JBM, JAMA 2012
Surgical vs Conventional Therapy for Weight Loss Treatment of
OSA – Apnea-Hypopnea Index

Dixon JBM, JAMA 2012
“I have lost that tendency to sleepiness which made me
think of the fat boy in Pickwick. My color is very much
better and my ability to work is greater.“
William H. Taft, Präsident der USA 1909-1913

Adapted from Randerath W




NIV consists of the application of intermittent
positive pressure ventilation, normally with
bilevel positive pressure, using nasal or nasooral masks.
NIV can improve nocturnal hypercapnia by:
 increasing alveolar ventilation,
 preventing obstructive events,
 improving leptin action (or preventing the

resulting central hypoventilation) and
 providing more efficient direct muscular repose.


Several series of cases and one RCT on 37
patients with mild hypercapnia [Borel 2012]
have shown improvements:
 in the clinical picture, arterial blood gases and sleep

disorders with this treatment [Massa, 2001].
 A reduction in days of hospital admission has been
observed in longitudinal studies [Berg G 2001].


NIV decreases mortality in a series of patients
treated with NIV, compared with other studies in
which patients were not treated or refused
treatment [Pepin 2012].
Borel et al, Chest 2012. RCT – 19 NIV (BiPAP) vs 18 Controls

Daytime PCO2

Sat mean

Sat < 90%

Respiratory
arousal


CPAP prevents obstructive events in patients
with OHS but the PaCO2 is not normalized in all
patients.



Only one RCT has evaluated the clinical, PaCO2
and polysomnographic improvements in CPAP
vs. NIV in 36 OHS patients selected for their
favorable response to an initial night of CPAP
treatment [Piper 2007].



More RCTs are need !

Piper AJ et Randomized trial of CPAP vs bi-level support in the treatment of Obesity
Hypoventilation Syndrome without severe nocturnal desaturation. Thorax 2008;63:395
Piper AJ, al. RCT: CPAP vs bi-level in OHS without severe nocturnal desaturation.
Thorax 2008

 This is the only RCT
comparing NIV vs CPAP in
36 OHS patients who
respond to an initial night
with CPAP treatment.
 The follow up was 3
months and there were no
differences in gas
exchange, sleepiness and
QL.
 The weakness of this
study is the selection of
patients (no severe
nocturnal desaturation)
Exclusion Criteria
Patients with persisting hypoventilation during initial CPAP Trial

Piper at al Thorax 63; 395-401
SpO2
HR

SpO2

HR

SpO2
HR
SpO2
HR

SpO2
HR

SpO2
HR

Hypercapnic OSA
SpO2
HR

SpO2
HR

SpO2
HR

Hypercapnic OSA

Hypercapnic OSA & OHS
SpO2
HR

SpO2

Hypercapnic OSA

Hypercapnic OSA & OHS

HR

SpO2
HR

Hypercapnic OHS
SpO2
HR

SpO2

Hypercapnic OSA

Hypercapnic OSA & OHS

HR

SpO2
HR

10% of Patients with OHS have no co-existent OSA1,2,3
1. Kessler et al. Chest 2001; 120:369-71
2. Perez de Llano et al . Chest 2005; 128: 587-594
3. Mohhlesi et al. Sleep Breath 2007; 11: 117-24
Does NIV (Bilevel) Influence Survival ?
3%
9%

20%
23%

Nowbar et al Am J Med 2004; 116: 58-9
Budweiser et al J Intern Med 2007; 261:375-383
Conclusão : (n=36) Este estudo
sugere uma relação entre
obesidade e restrição pulmonar
e aponta para um impacto
positivo da cirurgia bariátrica
na Função Respiratória .
IMC = 59,5 kg/m2
IAH = 76,8
SaO2 mínima = 67 %
SaO2 média = 83 %
IMC = 27,8 kg/m2
IAH = 2
SaO2 mínima = 94
SaO2 média = 95


Conclusões:
 Frequência elevada de Distúrbio Respiratório do Sono

em doentes candidatos a cirurgia de obesidade
 Limitação da predição de Distúrbio Respiratório do
Sono com base na apresentação clínica
 Face ao risco cirúrgico destes doentes o rastreio
sistemático com recurso a estudo do sono parece
mandatório
 A resolução do Distúrbio Respiratório do Sono com a
redução do peso é expectável na maioria dos doentes.
Hybrid Mode
Combine the advantages of pressure and
volume pre-set
 Target volume set based on ideal body weight
 Automatic adjustment of inspiratory pressure
(range setting)
 Difference between target VT and actual VT
modifies inspiratory pressure
 Changes of inspiratory pressure (1 cmH2O/min)
 Constant VT


*pre-post p<0.05

Follow up data
ST

AVAPS

PaCO2 (kPa)

6.1±0.9*

6.4±0.8*

PaO2 (kPa)

9.3±1.2

8.9±0.9

Weight

142±28*

139±29*

BMI

50±7

48±9*

ESS (/24)

7±5*

6±5*

58±14*

66±19*

Mean IPAP

23.2±3.1

21.5±5.0

Mean Vte

671±158

634±144

Mean Vte/kg ideal wgt

10.4±2.4

10.0±1.4

Compliance (hr/day)

5.7±1.9

4.2±2.9

SRI-SS (/100)
Follow up data
ST

AVAPS

PaCO2 (kPa)

6.1±0.9*

6.4±0.8*

PaO2 (kPa)

9.3±1.2

8.9±0.9

Weight

142±28*

139±29*

BMI

50±7

48±9*

ESS (/24)

7±5*

6±5*

58±14*

66±19*

Mean IPAP

23.2±3.1

21.5±5.0

Mean Vte

671±158

634±144

Mean Vte/kg ideal wgt

10.4±2.4

10.0±1.4

Compliance (hr/day)

5.7±1.9

4.2±2.9

SRI-SS (/100)

*pre-post p<0.05
Sindrome obesidade hipoventilação   tratamento cónico

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Sindrome obesidade hipoventilação tratamento cónico

  • 1.
  • 2. Severe obesity BMI > 30 kg/m2 and diurnal PaCO2 > 45 mmHg In the absence of other known cause of hypoventilation Adapted de Pépin, Borel, Tamisier, Lévy
  • 3. OR 4.0 Adjusting for age sex BMI Mortality is increased compared to “simple obesity” suggesting specific cardiovascular morbidity Nowbar. Am J Med 2004
  • 4.  Compared with eucapnic morbidly obese patients and eucapnic patients with sleep-disordered breathing, patients with OHS have increased health care expenses and are at higher risk of developing serious cardiovascular disease leading to early mortality.  Despite the significant morbidity and mortality associated with this syndrome, diagnosis and institution of effective treatment occur late in the course of the syndrome. Mokhlesi B, Kryger MH, Grunstein RR. Assessment and management of patients with obesity hypoventilation syndrome. Proc Am Thorac Soc. 2008
  • 5.  This is believed to be the ideal treatment for OHS.  Respiratory insufficiency, pulmonary hypertension and sleep disorders [Dixon JB 2012] can be reversed if patients achieve a normal weight, although only a few maintain a significant weight reduction for a long period.  Although bariatric surgery has been tested as an alternative treatment for OSA patients with extreme obesity, there are still some doubts about the benefit of this kind of therapy [Dixon JB 2012].  Less data are available in the case of OHS especially as regards the long-term consequences. [Douglas C, 2012]  Moreover, bariatric surgery can be an alternative for only a minority of OHS patients due to the morbidity and mortality inherent in the surgical procedure itself
  • 6. Behaviorally , diet and pharmacologically weight loss in OSA Douglas C. OSA and Weight Loss: Review. Sleep Disord. 2012
  • 8. Surgical vs Conventional Therapy for Weight Loss Treatment of OSA – BODY WEIGHT Dixon JBM, JAMA 2012
  • 9. Surgical vs Conventional Therapy for Weight Loss Treatment of OSA – Apnea-Hypopnea Index Dixon JBM, JAMA 2012
  • 10. “I have lost that tendency to sleepiness which made me think of the fat boy in Pickwick. My color is very much better and my ability to work is greater.“ William H. Taft, Präsident der USA 1909-1913 Adapted from Randerath W
  • 11.   NIV consists of the application of intermittent positive pressure ventilation, normally with bilevel positive pressure, using nasal or nasooral masks. NIV can improve nocturnal hypercapnia by:  increasing alveolar ventilation,  preventing obstructive events,  improving leptin action (or preventing the resulting central hypoventilation) and  providing more efficient direct muscular repose.
  • 12.  Several series of cases and one RCT on 37 patients with mild hypercapnia [Borel 2012] have shown improvements:  in the clinical picture, arterial blood gases and sleep disorders with this treatment [Massa, 2001].  A reduction in days of hospital admission has been observed in longitudinal studies [Berg G 2001].  NIV decreases mortality in a series of patients treated with NIV, compared with other studies in which patients were not treated or refused treatment [Pepin 2012].
  • 13. Borel et al, Chest 2012. RCT – 19 NIV (BiPAP) vs 18 Controls Daytime PCO2 Sat mean Sat < 90% Respiratory arousal
  • 14.  CPAP prevents obstructive events in patients with OHS but the PaCO2 is not normalized in all patients.  Only one RCT has evaluated the clinical, PaCO2 and polysomnographic improvements in CPAP vs. NIV in 36 OHS patients selected for their favorable response to an initial night of CPAP treatment [Piper 2007].  More RCTs are need ! Piper AJ et Randomized trial of CPAP vs bi-level support in the treatment of Obesity Hypoventilation Syndrome without severe nocturnal desaturation. Thorax 2008;63:395
  • 15. Piper AJ, al. RCT: CPAP vs bi-level in OHS without severe nocturnal desaturation. Thorax 2008  This is the only RCT comparing NIV vs CPAP in 36 OHS patients who respond to an initial night with CPAP treatment.  The follow up was 3 months and there were no differences in gas exchange, sleepiness and QL.  The weakness of this study is the selection of patients (no severe nocturnal desaturation)
  • 16. Exclusion Criteria Patients with persisting hypoventilation during initial CPAP Trial Piper at al Thorax 63; 395-401
  • 20. SpO2 HR SpO2 Hypercapnic OSA Hypercapnic OSA & OHS HR SpO2 HR Hypercapnic OHS
  • 21. SpO2 HR SpO2 Hypercapnic OSA Hypercapnic OSA & OHS HR SpO2 HR 10% of Patients with OHS have no co-existent OSA1,2,3 1. Kessler et al. Chest 2001; 120:369-71 2. Perez de Llano et al . Chest 2005; 128: 587-594 3. Mohhlesi et al. Sleep Breath 2007; 11: 117-24
  • 22. Does NIV (Bilevel) Influence Survival ? 3% 9% 20% 23% Nowbar et al Am J Med 2004; 116: 58-9 Budweiser et al J Intern Med 2007; 261:375-383
  • 23.
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  • 28.
  • 29. Conclusão : (n=36) Este estudo sugere uma relação entre obesidade e restrição pulmonar e aponta para um impacto positivo da cirurgia bariátrica na Função Respiratória .
  • 30. IMC = 59,5 kg/m2 IAH = 76,8 SaO2 mínima = 67 % SaO2 média = 83 %
  • 31. IMC = 27,8 kg/m2 IAH = 2 SaO2 mínima = 94 SaO2 média = 95
  • 32.  Conclusões:  Frequência elevada de Distúrbio Respiratório do Sono em doentes candidatos a cirurgia de obesidade  Limitação da predição de Distúrbio Respiratório do Sono com base na apresentação clínica  Face ao risco cirúrgico destes doentes o rastreio sistemático com recurso a estudo do sono parece mandatório  A resolução do Distúrbio Respiratório do Sono com a redução do peso é expectável na maioria dos doentes.
  • 33.
  • 34. Hybrid Mode Combine the advantages of pressure and volume pre-set  Target volume set based on ideal body weight  Automatic adjustment of inspiratory pressure (range setting)  Difference between target VT and actual VT modifies inspiratory pressure  Changes of inspiratory pressure (1 cmH2O/min)  Constant VT  
  • 35. *pre-post p<0.05 Follow up data ST AVAPS PaCO2 (kPa) 6.1±0.9* 6.4±0.8* PaO2 (kPa) 9.3±1.2 8.9±0.9 Weight 142±28* 139±29* BMI 50±7 48±9* ESS (/24) 7±5* 6±5* 58±14* 66±19* Mean IPAP 23.2±3.1 21.5±5.0 Mean Vte 671±158 634±144 Mean Vte/kg ideal wgt 10.4±2.4 10.0±1.4 Compliance (hr/day) 5.7±1.9 4.2±2.9 SRI-SS (/100)
  • 36. Follow up data ST AVAPS PaCO2 (kPa) 6.1±0.9* 6.4±0.8* PaO2 (kPa) 9.3±1.2 8.9±0.9 Weight 142±28* 139±29* BMI 50±7 48±9* ESS (/24) 7±5* 6±5* 58±14* 66±19* Mean IPAP 23.2±3.1 21.5±5.0 Mean Vte 671±158 634±144 Mean Vte/kg ideal wgt 10.4±2.4 10.0±1.4 Compliance (hr/day) 5.7±1.9 4.2±2.9 SRI-SS (/100) *pre-post p<0.05

Notas del editor

  1. Doençaheterogenea