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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