Obesity Hypoventilation Syndrome

Obesity Hypoventilation Syndrome

Teeradej Kuptanon, MD

Division of Pediatric Pulmonology,Ramathibodi Hospital, Mahidol University

Teeradej Kuptanon, MD

Division of Pediatric Pulmonology,Ramathibodi Hospital, Mahidol University

PP; เด็กหญิงไทย อาย ุ8 ป กทม. ประวัติจาก มารดา

CC หายใจหอบเหนื่อยตอนกลางคืนมากข้ึนมา2 คืน

PI อายุ 3-4 ป เริ่มกรนอายุ 6 ป กรนมากข้ึนเรื่อย ๆ กรนดังมาก ขนาดปดประตูหองยังไดยินเสียงกรน หายใจแรงทุกคืน บางครั้งมีหายใจเฮือกมาใหม เปลี่ยนทาไมหายนอนกรน

2-3 เดือนกอนมาโรงพยาบาล กรนดังมากข้ึน

หยุดหายใจเปนชวง ๆ คืนละหลายครั้ง ดูปากเขียวซีด

บางครั้ง กลางวันงวงมาก

2-3 วันกอนมาโรงพยาบาล หายใจลําบากมากข้ึน กรนดังข้ึนอีก เขียวบอยข้ึน ปากเขียว ตัวเขียวมารดา จึงพามาโรงพยาบาล

PE: T 37 oC, RR 32/min, PR 120/min BP 120/70 mmHg., BW 50 kg(>P97), Ht 120 cm(P25-50) Wt for Ht.>P50 217%, BMI 35

GA obesity, good consciousness, acanthosis nigricans

HEENT tonsils 3+ not injected, dental cariesnose; swollen nasal turbinate

• Heart; normal S1 S2, no murmur, equally pulses all extremities

• Lungs no retraction. breath sound ฟงไมคอยไดยินเพราะchest wall หนาจากความอวน

• ABD: soft, not distended, liver&spleen-not palpable

• EXT.: no rash, BCG+

• Heart; normal S1 S2, no murmur, equally pulses all extremities

• Lungs no retraction. breath sound ฟงไมคอยไดยินเพราะchest wall หนาจากความอวน

• ABD: soft, not distended, liver&spleen-not palpable

• EXT.: no rash, BCG+

แพทยรับตัวไวในโรงพยาบาล เนื่องจาก ขณะที่เด็กนอนหลับ SpO2 drop เหลือ 80-85% จึงให oxygen ผาน nasal canula 4 LPM SpO2 สูงขึ้นเปน 95-97%

หลังจากให oxygen และเด็กหลับไป 3 ชั่วโมง พยาบาลสังเกตวาเด็กเขียว วัด oxygen saturation ไดขึ้น ๆ ลง ๆ อยูระหวาง 50% ถึง 80% พยายามเขยาตัวเพื่อปลุกแตเด็กไมยอมต่ืน นอนหลับสนิท มีเสียงกรนดังมาก จัดทานอนใหเปนทาตะแคงก็ไมดีขึ้น SpO2 ยังตํ่าตลอด อยูระหวาง 50% -80% เพิ่ม oxygen ก็ไมดีขึ้น

Central chemorecepterCentral chemorecepter

PaO2Peripheral chemorecepter

(carotid bodies)

CO2

CO2 NarcosisCO2 Narcosis

Central chemorecepterCentral chemorecepter

PaO2Peripheral chemorecepter

(carotid bodies)

CO2

Central chemorecepterCentral chemorecepter

PaO2Peripheral chemorecepter

(carotid bodies)

CO2

Oxygen theraphy

Charles Dickens 1836 ‘The Pickwick papers’

Undiagnosed OHSUndiagnosed OHS

• Increased health care costs• Increased need for ICU monitoring• Higher requirement for invasive

mechanical ventilation• Worse quality of life• Higher risk for pulmonary hypertension• Increased risk for death

• Increased health care costs• Increased need for ICU monitoring• Higher requirement for invasive

mechanical ventilation• Worse quality of life• Higher risk for pulmonary hypertension• Increased risk for death

DefinitionDefinitionBMI > 30 kg/m2

Daytime hypercapniaSleep disorder breathing

BMI > 30 kg/m2

Daytime hypercapniaSleep disorder breathing

Common causes of hypercapnia other than obesity hypoventilation syndrome

Common causes of hypercapnia other than obesity hypoventilation syndrome• Chest wall restrictive disorders (eg, scoliosis)• Severe interstitial lung disease• Severe obstructive lung disease (FEV1 < 1 L or < 35%

predicted)• CNS structural defects – tumor, cerebrovascular

accidents, brainstem or spinal cord lesions• Neuromuscular disorders• Severe hypothyroidism/myxedema• Severe electrolyte abnormalities (eg, hypophosphatemia

and hypocalcemia)• Idiopathic central alveolar hypoventilation• Metabolic alkalosis caused by high doses of loop

diuretics

• Chest wall restrictive disorders (eg, scoliosis)• Severe interstitial lung disease• Severe obstructive lung disease (FEV1 < 1 L or < 35%

predicted)• CNS structural defects – tumor, cerebrovascular

accidents, brainstem or spinal cord lesions• Neuromuscular disorders• Severe hypothyroidism/myxedema• Severe electrolyte abnormalities (eg, hypophosphatemia

and hypocalcemia)• Idiopathic central alveolar hypoventilation• Metabolic alkalosis caused by high doses of loop

diuretics

PathophysiologyPathophysiology1. Leptin resistance2. Increase mechanical load3. Sleep disorder breathing

1. Leptin resistance2. Increase mechanical load3. Sleep disorder breathing

Obesity

Leptin resistanceIncreased mechanical load

and weak respiratory muscles

OSA

Upper airway resistance

Acute hypercapnia during sleep

Increased serum bicarbonate

Blunted ventilatory response

Chronic hypercapnia Mokhlesi, B et al., Recent Advances in

Obesity Hypoventilation Syndrome, Chest

Blood Brain BarrierBlood Brain Barrier

Symptoms & SignsSymptoms & SignsHistory

SnoreDyspneaApneaMorning headacheCor-pulmonalMedication

HistorySnoreDyspneaApneaMorning headacheCor-pulmonalMedication

Physical examinationPlethoric obeseSomnolentCrowded oropharynxRapid shallow breathing

Increase P2

Physical examinationPlethoric obeseSomnolentCrowded oropharynxRapid shallow breathing

Increase P2

LaboratoryLaboratoryArterial Blood GasSerum BicarbonatePulmonary function test ( Restrictive lung )

CBC, CXR, EKG, EchocardiogramThyroid function Sleep study

Arterial Blood GasSerum BicarbonatePulmonary function test ( Restrictive lung )

CBC, CXR, EKG, EchocardiogramThyroid function Sleep study

After intubation

After intubationInteresting case

TPRC TPRC

LABORATORY INVESTIGATIONLABORATORY INVESTIGATION

• CBC; Hb 11.8 g/dL, Hct 35.5%, WBC 13,600(N56%, L33%, M8%, E2%, B1%),Plt 440,000k/ul

• UA; Sp.gr. 1.020, pH6.0, prot-trace, glu-ve, WBC 3-5, RBC 0-1

• ABG; pH 7.32, pCO2 70, HCO337, pO2 54.1

• CBC; Hb 11.8 g/dL, Hct 35.5%, WBC 13,600(N56%, L33%, M8%, E2%, B1%),Plt 440,000k/ul

• UA; Sp.gr. 1.020, pH6.0, prot-trace, glu-ve, WBC 3-5, RBC 0-1

• ABG; pH 7.32, pCO2 70, HCO337, pO2 54.1

TreatmentTreatmentWeight reductionPositive airway pressure

OxygenMedicationBariatric surgeryTracheostomy

Weight reductionPositive airway pressure

OxygenMedicationBariatric surgeryTracheostomy

PAO2 = (FiO2 x 713) - PaCO2

HypoventilationHypoventilation

PAO2 PaCO2

OO22

COCO22

R

Noninvasive positive pressure ventilationNoninvasive positive pressure ventilation

ObjectivesRelieve upper airway obstructionIncrease alveolar ventilation

SettingLocal expertiseStaff familiarFollow up

ObjectivesRelieve upper airway obstructionIncrease alveolar ventilation

SettingLocal expertiseStaff familiarFollow up

เคร่ืองชวยหายใจ Corrugated tube Exhalation port หนากากสายรัดหนากาก

NIPPV SYSTEM

Nasal maskNasal mask Full face maskFull face mask

Contraindications to noninvasive positive pressure ventilation

Contraindications to noninvasive positive pressure ventilation

• Hemodynamic instability or unstable cardiac arrhythmia

• Inability to protect airway • adequately clear secretions

• Hemodynamic instability or unstable cardiac arrhythmia

• Inability to protect airway • adequately clear secretions

Pressure TitrationPressure Titration

• CPAPincrease pressure until

Eradicate apnea, hypopnea, snoring, desaturation

• BiPAPEPAP Eradicate apneaIPAP Eradicate hypopnea, snoring,

desaturation

• CPAPincrease pressure until

Eradicate apnea, hypopnea, snoring, desaturation

• BiPAPEPAP Eradicate apneaIPAP Eradicate hypopnea, snoring,

desaturation

• CPAP usually not more than 13 cmH2O • BiPAP pressure difference IPAP/EPAP

at least 6 cmH2O not more than 15 cmH2O

• Back up rate ~ 20 times/min

• CPAP usually not more than 13 cmH2O • BiPAP pressure difference IPAP/EPAP

at least 6 cmH2O not more than 15 cmH2O

• Back up rate ~ 20 times/min

Dement WC, et al. Brain Respiratory, 1974.

IPAP 10EPAP 4

BiPAP setting

HypopneaIPAP 11EPAP 4

ApneaIPAP 12EPAP 5

Pressure

Time

Clinical features suggestive of NIPPV failure

Clinical features suggestive of NIPPV failure

Poor tolerance of the interfaceLack of improvement in tachynea and dyspneaIncrease use of accessory muscles with

impending respiratory failureHypotension or bradycardiaPersistent and refractory hypoxemiaPH persistently less than 7.25 or lack of

improvement in hypercapnia after 1-2 hours

Poor tolerance of the interfaceLack of improvement in tachynea and dyspneaIncrease use of accessory muscles with

impending respiratory failureHypotension or bradycardiaPersistent and refractory hypoxemiaPH persistently less than 7.25 or lack of

improvement in hypercapnia after 1-2 hours

MedicationsMedications

ProgesteroneAlmitrine Acetazolamide Leptin

ProgesteroneAlmitrine Acetazolamide Leptin

Follow upFollow up

ABGSerum BicarbonateABGSerum Bicarbonate

SummarySummaryObesity hypoventilation syndromeCO2 Narcosis NIPPV is the treatment of choice in acute

and chronic hypercapnic respiratory falurein OHS patients

Multidisciplinary approach Doctor, Nurse, Emergency ward, IPD, ICU

Obesity hypoventilation syndromeCO2 Narcosis NIPPV is the treatment of choice in acute

and chronic hypercapnic respiratory falurein OHS patients

Multidisciplinary approach Doctor, Nurse, Emergency ward, IPD, ICU