Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep...
Transcript of Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep...
![Page 1: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/1.jpg)
The Big and the BreathlessSleep Related Hypoventilation
Jagdeep Bijwadia MDDepartment Head,
Pulmonary Critical Care and Sleep MedicineHealthPartners Medical Group
Assistant Professor University of MNDivision of Pulmonary Allergy Critical Care and Sleep
![Page 2: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/2.jpg)
1. rObjectives
• Respiratory physiology during sleep• Definition and Physiology of Obesity
hypoventilation• Morbidity of the disease• Treatment: benefits and options• HealthPartners experience
![Page 3: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/3.jpg)
Carbon Dioxide
![Page 4: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/4.jpg)
Atmospheric Concentrations of CO2
![Page 5: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/5.jpg)
Carbon Dioxide Emissions
![Page 6: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/6.jpg)
Respiratory Physiology during Sleep
![Page 7: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/7.jpg)
Sleep Hypnogram
![Page 8: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/8.jpg)
Some Generalizations
• Sleep is entered through NREM• NREM and REM alternate with
approximately 90 minute periods• REM sleep predominates in the latter third
of the night• Wakefulness within sleep usually accounts
for less than 5% of total sleep time.
![Page 9: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/9.jpg)
Brain Res 1974 ;82 Montplasir et al
Downloaded from: Principles and Practice of Sleep Medicine (on 24 April 2005 03:27 PM)© 2005 Elsevier
![Page 10: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/10.jpg)
Downloaded from: Principles and Practice of Sleep Medicine (on 24 April 2005 03:27 PM)
Clin Chest Med 1985;6 Douglas
![Page 11: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/11.jpg)
Clin Chest Med1985;6 Douglas et al)
© 2005 Elsevier
![Page 12: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/12.jpg)
Compliance associated with AHI reductioneven when used < 20 hours/week
Hours/week % of patients Initial AHI At Home
>50 11% 40.4 3.4
40-50 18% 37.3 4.0
30-40 17% 33.6 4.7
20-30 14% 31.4 4.3
<20 39% 26.9 5.2
![Page 13: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/13.jpg)
Effects of Sleep on Ventilatory Function
• Minute ventilation is decreases by 6-11% in NREM and 5-15% in REM sleep
• CO2 rises between 2 and 6.5 mm Hg
• Decrease in oxygen saturation occurs NREM 96.5, REM 96.2 (wakefulness 97.3)
• The upper airway lumen is reduced during sleep, this is more pronounced in snorers
![Page 14: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/14.jpg)
Unique Effects of REM Sleep on Ventilation
• The respiratory rate is increased and irregular especially in phasic REM
• The diaphragm: dominant muscle maintaining ventilation
• The upper airway is more susceptible to closure via negative pressure
• Apneas are longer and there is reduced susceptibility to recovery central apneas
![Page 15: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/15.jpg)
Hypoventilationmechanisms
0.863 x VC02
VE x (1- VD/VT)PC02 =
VC02
VE
VD/VT
PC02
![Page 16: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/16.jpg)
Hypoventilationmechanisms
PC02
VE7
40a
80 b
3.5
PC02P02
Increasing VD/VTVC02
aa
![Page 17: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/17.jpg)
Causes of Hypercapnic Resp. Failure
Neural & Neuromuscular• Brain
– Drugs• Motor neurons• Neuromuscular junction• Respiratory muscles
Chest Wall• Kyphoscoliosis• Ankylosing spondylitis• Flail chest
“Medical” Diseases• COPD• Severe asthma• Late stage interstitial lung
disease• Pulmonary edema• Sleep apnea / obesity-
hypoventilation• Hypothyroidism
Iatrogenic - Drugs, Ventilators
![Page 18: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/18.jpg)
Clinical Categories of Hypoventilation
• Can’t breathe:dyspnea due to mechanical restraint, weakness, or excessive ventilation.
• Won’t breathe:no dyspnea. Depressed drive due to congenital or acquired controller error.
![Page 19: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/19.jpg)
Can’t breathe
-Airway Obstruction• COPD, asthma, cystic fibrosis
-Restrictive• Obesity• Kyphoscoliosis
-Weakness• ALS/myopathies
![Page 20: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/20.jpg)
Can’t Breathe
KyphoscoliosisAngle > 90o COPD Fev1 < 30% Obesity + OSA
![Page 21: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/21.jpg)
Won’t breathe
• Exogenous: narcotics, sedatives.
• Endogenous:Leptin resistance1-5, alkalosis, myxedema, adaptation, genetic6-10, structural.
![Page 22: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/22.jpg)
Hypercapnic Disorders: Definitions
Hypercapnia: PaCO2 ≥ 45 mm Hg
Hypercapnic respiratory failure: Hypercapnia plus Acidosis
– Acute: no or minimal metabolic compensation– Chronic: appropriate metabolic compensation
![Page 23: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/23.jpg)
• Triad of obesity, daytime hypoventilation and sleep disordered breathing
• Often a diagnosis of exclusion
• Prevalence of OHS amongst patients with a BMI>35 has been reported as 31%
Why some subjects develop OHS whilst others do not at the same BMI is not completely understood
Obesity Hypoventilation Syndrome
![Page 24: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/24.jpg)
![Page 25: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/25.jpg)
Definitions: BMI
• 25 ideal• >30 obese• >40 morbid obesity• >50 super obese• >60 super super obese
![Page 26: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/26.jpg)
(a) Urban
Obesity in India
![Page 27: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/27.jpg)
7506 overnight OSA diagnostic studies
1844 with CPAP compliance data
Overall AHI reduction 32.1 4.6
BMI ≥ 40 – 444 patients BMI < 40 – 1399 patients
AHI reduction 43.2 4.9 AHI reduction 28.7 4.5
HPMG Data
![Page 28: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/28.jpg)
Breathing patterns with Obesity
• Heavy snoring • Hypoxemia without OSA (hypoventilation)• OSA• OHS
![Page 29: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/29.jpg)
OHS
OSA No OSA
90% 10%
OSACO2 Normal CO2
Eucapnic OSA
![Page 30: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/30.jpg)
Obesity Hypoventilation Syndrome(OHS)
• Definition– BMI > 30 kg/m2
– Awake arterial pCO2 > 45 mm Hg– No other causes for hypercapnia
![Page 31: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/31.jpg)
![Page 32: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/32.jpg)
![Page 33: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/33.jpg)
Pickwickian Syndrome
Little boy whowould always
fall asleep
![Page 34: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/34.jpg)
![Page 35: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/35.jpg)
OHS: Incidence
• 0.3-0.5% of the general population• 10-20% in outpatients presenting to sleep
clinics• 50% of hospitalized patients with BMI over
50
![Page 36: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/36.jpg)
Eucapneic OSA versus OHS
• Upper airway resistance• Distribution of obesity• Pulmonary mechanics• Responsiveness to carbon dioxide and oxygen• Leptin resistance
![Page 37: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/37.jpg)
Eucapnic OSA versus OHS
• Increased healthcare utilization• Poorer health outcomes• Greater hypersomnia• Lower level of social functioning• More likely to have CHF, angina, cor
pulmonale• Increased severity of pulmonary HTN
![Page 38: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/38.jpg)
Eucapnic OSA versus OHS
• More likely to be hospitalized• More vulnerable to iatrogenic insults• Longer ICU stays • Increased likelihood of LTAC need• Higher mortality
![Page 39: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/39.jpg)
Hypoxemia + HypercapniaPulmonary Hypertension
![Page 40: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/40.jpg)
100
90
80
70
60
50
0 2 4 6 8 10 12 14 16 18
Months after Hospital Discharge
Prob
abili
ty o
f Sur
viva
l (%
)
Nowbar Am J Med 2004
Post Hospitalization Mortality
![Page 41: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/41.jpg)
![Page 42: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/42.jpg)
Proposed Mechanisms for OHS
• Ventilatory load
• Sleep Disordered breathing
• Abnormal Ventilatory control mechanisms
![Page 43: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/43.jpg)
Respiratory Mechanics in OHS
OHS Eucapnic obesityFEV1/FVC normal normalTLC slightly reduced normalERV Markedly reduced normal/mildly reducedInspiratory muscle strength
reduced normal
Ventilatory response to CO2
Normal/reduced normal/increased
pCO2 increased normal
![Page 44: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/44.jpg)
![Page 45: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/45.jpg)
Effects of obesity on upper airway
![Page 46: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/46.jpg)
![Page 47: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/47.jpg)
![Page 48: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/48.jpg)
Proposed Mechanisms for OHS
• Ventilatory load
• Sleep Disordered breathing
• Abnormal ventilatory control mechanism
![Page 49: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/49.jpg)
![Page 50: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/50.jpg)
0
10
20
30
40
50
60
70
80
arousalindex
percentsleep time
withsaturation
less than 90
OSA OHS
![Page 51: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/51.jpg)
Daytime Hypercapnia in OHS
• Shorter inter-apneic recovery• Inability to bring pCO2 back to baseline
before the onset of the next apnea• Elevations of bicarbonate• Abnormality in bicarbonate handling by the
renal system
![Page 52: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/52.jpg)
© 2012 American Society of Anesthesiologists, Inc. Published by American Society of Anesthesiologists, Inc. 2
Fig. 3
![Page 53: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/53.jpg)
Proposed Mechanisms for OHS
• Ventilatory load
• Sleep Disordered breathing
• Abnormal Ventilatory Control Mechanisms
![Page 54: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/54.jpg)
Evidence of Abnormal Ventilatory control
• Pts with OHS do not hyperventilate to the same degree when rebreathing CO2
• Pts with OHS do not increase their minute ventilation to the same degree when forced to breath a hypoxic gas mixture
![Page 55: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/55.jpg)
Abnormal Ventilatory ControlAcquired
• The ventilatory responses to hypercapniaare similar between first degree relatives of pts with OHS and controls
• Treatment with PAP therapy improves the responsiveness to hypercapnia and hypoxia
![Page 56: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/56.jpg)
The leptin story
![Page 57: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/57.jpg)
Ventilation
![Page 58: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/58.jpg)
Leptin resistance in OSAH
Shimura R, Chest 2005;127:543-9
PCO2<45 (106) PCO2>45 (79) p
BMI 32.5 + 0.3 33.2 + 0.8 NSFEV1/FVC, % 84.2 + 0.6 85.4 + 1.7 NSPaCO2, mm Hg 40.9 + 0.3 46.6 + 0.4 < 0.01AHI 52.9 + 2.2 47.4 + 2.8 NSLeptin, ng/mL 9.0 + 0.4 14.3 + 1.0 < 0.01
Caro JF. . Lancet 1996; 348:159–161
Leptin resistance in obesityleptin CSF/serum ratio is fourfold
higher in lean individuals compared to obese subjects
![Page 59: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/59.jpg)
Treatment of OHS
Address reversible causesMedicationsOxygenPAP: CPAP, BIPAP, AVAPStracheostomy
![Page 60: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/60.jpg)
Treatment of OHS
Weight loss
![Page 61: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/61.jpg)
Weight loss and OHSZavosky: Review of 14 studies 288 patients, mean period of follow up 18 months (12% of patients had OHS)PaO2 increased by 10, PaCO2 decreased by 3
Torchia: Surgical Rx of 95 patients with BMI of >60 OSA/OHS 39% 12 months follow up 30 of 35 had resolution with improvement in the remaining 5
(Surgical series of 34 pts with BMI >70, 58% had OSA 32% had OHS)
![Page 62: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/62.jpg)
No in BMI after Dx (7505 patient database)
mean BMI - s.d.
0
5
10
15
20
25
30
35
40
45
50
Initial 6 months 1 year
HPMG Data
![Page 63: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/63.jpg)
Non-PAP TherapyStimulants for Hypoventilation
• Progesterone- modestly lowers PCO21; improves
hypoventilation2 but not OSA3
• Acetazolamide- may worsen OSA, less effective than progesterone in hypoventilation1
• Thyroid replacement in myxedema
1Skatrud JB. Progress in Clinical & Biological Research. 136:87-95, 1983 2Hudgel DW. American Journal of Respiratory and Crit Care Medicine158:691-9, 1998 3Cook W. Chest 1989;96(2):262-6
![Page 64: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/64.jpg)
Effect of supplemental oxygen on hypercapnia in OHS
![Page 65: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/65.jpg)
The Effect of Supplemental Oxygen on Hypercapnia in Subjects With Obesity-Associated Hypoventilation
![Page 66: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/66.jpg)
Positive airway pressure treatment
• CPAP
• BIPAP
• BIPAP with Backup rate
• AVAPS
![Page 67: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/67.jpg)
100
90
80
70
60
50
0 2 4 6 8 10 12 14 16 18
OHS treated with NIV Eucapnic obesity Untreated OHS
Months after diagnosis of OHS
% P
roba
bilit
y of
Sur
viva
l
![Page 68: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/68.jpg)
PAP in restrictive disease
Simonds AK Thorax 1995;50:604-609
75
60
P02
PC02
YEARS 0 1 2 3 4 545
![Page 69: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/69.jpg)
Obesity hypoventilation syndrome
Predominant OSA
Predominant Hypoventilatiion
CPAPBIPAP
BIPAP +BURAVAPS
![Page 70: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/70.jpg)
CPAP Effective ~99%
![Page 71: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/71.jpg)
CPAP• One level of pressure on inspiration and exhalation• Device may have the option to provide pressure relief in early
exhalation
5 cmH2
0
71
![Page 72: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/72.jpg)
CPAP for Obesity Hypoventilation
• Often successful when the predominant physiology is one of airway obstruction
• May result in lowering of pCO2 and increase in pO2
![Page 73: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/73.jpg)
CPAP for OHS
Current Evidence Supports:
Improvement in awake blood gasesVentilatory responsiveness to hypoxemia and hypercapniaImproved V/Q mismatchReduced diaphragmatic effortImproved quality of life
![Page 74: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/74.jpg)
Greater HTN reduction if BMI>40?
120
130
140
150
160
170
180
initial 6 months
>40
<40
HPMG data
![Page 75: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/75.jpg)
If BMI >40, compliance matters if initial SBP>150
120
130
140
150
160
170
Initial 6 months
>40 hours<40
![Page 76: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/76.jpg)
Daytime Hypercapnia in Obstructive Sleep Apnea Syndrome
Naoko Kawata, MD Chest 2007
![Page 77: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/77.jpg)
Bi-level therapy
• One level of pressure on inspiration and lower level of pressure on expiration. PS the same every breath
cmH20
Bi-Level
77
![Page 78: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/78.jpg)
• OSA often coexists and this component is addressed by EPAP
• Tidal volume support is provided by the difference between EPAP and IPAP
• Oxygen may be needed if hypoxemia is not adequately corrected with BIPAP alone
BIPAP for Hypoventilation
![Page 79: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/79.jpg)
![Page 80: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/80.jpg)
BIPAP and OHS
• Current Evidence supports:
• Reduction in need for hospitalization• Improvements in secondary polysythemia• Improved sleep quality• Reduced inspiratory muscle loading
![Page 81: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/81.jpg)
Thorax 2008;63:395-401
Sleep-disordered breathing
Randomised trial of CPAP vs bilevel support in the treatment of obesity hypoventilation syndrome without severe nocturnal desaturation
A J Piper; D Wang; B J Yee; D J Barnes; R R Grunstein
![Page 82: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/82.jpg)
Conclusions
• Siimilar reductions in PCO2• Similar compliance• No difference in daytime sleepiness
• BIPAP group had increased psychomotor vigilance and subjective sleep quality
![Page 83: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/83.jpg)
• The treatment is targeted to provide a specified tidal volume support
• The amount of support provided by the machine can constantly adjust to the patients needs over time.
• May result in lower mean pressures compared to BIPAP
AVAPs for Hypoventilation
![Page 84: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/84.jpg)
AVAPS
Time
Pressure
Volume
Desired volume
IPAP
< 1 cmH2O / min
![Page 85: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/85.jpg)
AVAPS algorithm
1 minute
Breath
1 minute1 minute
1 minute
Time
![Page 86: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/86.jpg)
Date of download: 2/3/2013
Copyright © American College of Chest Physicians. All rights reserved.
Average Volume-Assured Pressure Support in Obesity Hypoventilation*: A Randomized Crossover Trial
CHEST. 2006;130(3):815-821. doi:10.1378/chest.130.3.815
Ptcco2 during the night at baseline, and during therapy with CPAP, BPV-S/T, and BPV-S/T-AVAPS.
Figure Legend:
![Page 87: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/87.jpg)
Date of download: 2/3/2013
Copyright © American College of Chest Physicians. All rights reserved.
Average Volume-Assured Pressure Support in Obesity Hypoventilation*: A Randomized Crossover Trial
CHEST. 2006;130(3):815-821. doi:10.1378/chest.130.3.815
Summary scale of the SRI at baseline, and following therapy with BPV-S/T and BPV-S/T-AVAPS.
Figure Legend:
![Page 88: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/88.jpg)
Conclusion
• BPV-S/T substantially improved oxygenation and sleep quality in patients with OHS.
• AVAPS provided additional benefits on ventilation quality, However, this did not provide further clinical benefits regarding sleep quality and HRQL.
![Page 89: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/89.jpg)
![Page 90: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/90.jpg)
![Page 91: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/91.jpg)
AVAPS
BIPAP/BUR
CPAP
![Page 92: Sleep Related Hypoventilation - University of Minnesota · Sleep Related Hypoventilation Jagdeep Bijwadia MD Department Head, ... • AVAPS provided additional benefits on ventilation](https://reader031.fdocuments.net/reader031/viewer/2022022016/5b662fe07f8b9a2f5c8c99d8/html5/thumbnails/92.jpg)
Pearls
• OHS is becoming more common with the obesity epidemic and has significant adverse consequences when not recognized
• An understanding of the underlying mechanisms is evolving
• Treatment is effective and improves outcomes• Weight loss and PAP are the mainstays of
treatment• Multimodality approaches likely to be needed