BMI ( ) kg / m 2 (P < 0.001) OSAS ( ) ( ) cm P < OSAS OSAS

Transcription

1 CHEST Luca Busetto, MD; Giuliano Enzi, MD; Emine Meral Inelmen, MD; Gabriella Costa, MD; Valentina Negrin, MD; Giuseppe Sergi, MD; and Andrea Vianello, MD (OSAS) OSAS 17 OSAS (BMI) ( ) kg / m 2 6 mo BMI ( ) kg / m 2 (P < 0.001) OSAS ( ) ( ) cm P < ( ) ( ) cm P < ( ) ( ) cm P < OSAS (AHI) ( ) ( ) ( ) / h P < OSAS OSAS OSAS 15% OSAS (obesity); (obstructive sleep apnea syndrome); (weight loss) AHI = apnea-hypopnea index; BMI = body mass index; ESS = Epworth sleepiness scale; NMR = nuclear magnetic resonance; OSAS = obstructive sleep apnea syndrome; Spo 2 = pulse oximetric saturation 218

2 (OSAS) 3mo [1] 40% >3 kg OSAS [2] [3] [4] OSAS OSAS [5] OSAS (BioEnterics [6, 7] Intragastric Balloon INAMED Health Santa [5] Barbara CA) ml [11] OSAS [8] [9] 2wk 2 wk OSAS 24 h 2.5 MJ ( 40% 25% 35%) 6 mo [12] 18 OSAS [13] OSAS [10] [14] BMI > 40 kg / m 2 BMI > 50 kg / m 2 ( ) Fleisch (Biomedin Padova Italy) [15] FVC FEV 1 FEV 1 / FVC Vilijanen [16] (Spo 2 ) (8500A Nonin From the Obesity Unit (Drs. Busetto, Enzi, Inelmen, Costa, Plymouth MN) Sergi, and Negrin), Department of Medical and Surgical Sciences, and the Unit of Respiratory Pathophysiology (Dr. Vianello), University of Padova, Padova, Italy. Correspondence to: Luca Busetto, MD, Clinica Medica I- ( ) PoliclinicoUniversitario, Via Giustiniani 2, Padova, Italy; luca.busetto@unipd.it ( ) ( ) CHEST

3 ( ) (Poly-Mesam MAP Martinsried Germany) _ 10 s x s 10 s ( Wilcoxon 1 Mann-Whitney U 10 s) ( 50% (SSPS s) SPSS Chicago IL) [17] (AHI) OSAS Epworth (ESS) ESS mo [18] 0 ( ) 24 ( ) 17 1 BMI 46.0 (EccoVision 82.0 kg / m 2 SensorMedics Pembroke, MA) Spo 2 (P < 0.001) [19, 20] AHI > 20 / h > 50 / h( 76.5%) ( ) kg ( kg) (14.5 ( cm 2 ) 8.9) % BMI ( 1) Martin [21] Spo 2 OSAS ( 1) 2 4 Spo 2 AHI ESS 220

4 ( ) ( ) cm P < ( ) ( ) cm P < ( ) ( ) cm 2 P < 0.01 ( ) ( ) cm 2 P < 0.01 ( ) ( ) cm 2 P < 0.05 ( ) ( ) cm 2 P < 0.01 ( ) ( ) cm 2 ( ) ( ) cm 2 ( ) % ( ) % BMI (r = P < 0.05) (r = P < 0.05) (r = P < 0.01) 3 /kg (2) /kg m (2) /cm (2) /cm (2) /cm (2) FVC / % FEV 1 /% FVC / FEV 1 /% Spo 2 /% Spo 2 /% (4) / (4) / / / AHI / h (4) ESS (2) _ x s (2) P < P < 0.05 (4) P < 0.01 Wilcoxon OSAS AHI 50% AHI < 20 / h [22] 58.8% (10 / 17) ( ) % ( ) % P< % Spo 2 AHI ESS 12.2% (r) SAD (BMI kg / m 2 ) BMI ( ) ( ) kg / m 2 P < ( ) ( ) cm P < FVC FEV Spo (2) (2) (2) Spo (2) (2) AHI ESS P < 0.05 (2) P < 0.01 SAD CHEST

5 3 (2, 4) /cm (5) (4) (2) 0 OPJ PHAR GLOT OPJ PHAR GLOT 1 ( ) ( ) ( ) OPJ PHAR GLOT P < 0.05 (2) P < 0.01 P < (4) Mann-Whitney U P < 0.05 (5) P < 0.01 Wilcoxon ( 1) OSAS ( ) ( ) cm 2 P < 0.01 (1.78 OSAS 0.32) ( ) cm 2 P < ( ) ( ) cm 2 P < 0.05 ( ) ( ) cm 2 P < 0.01 ( ) ( ) cm 2 [19, 20] ( ) ( ) cm 2 [21, 23, 24] OSAS (r = P < 0.05) [25] [25] (r = P < 0.05) (r = P < 0.01) (r = P < 0.05) 4 <5% OSAS 222

6 OSAS CT [26, 27] OSAS OSAS Horner [6] OSAS OSAS OSAS [6] [30] [5] OSAS [4] ( ) OSAS AHI OSAS Shelton [5] 2 1 Malhotra A, et al. Lancet 2002;360: Rajala R, et al. J Intern Med 1991;230: AHI ( ) 3 Shinohara E, et al. J Intern Med 1997;241: Davies RJO, et al. Thorax 1992;47: Horner RL, et al. Eur Respir J 1989;2: [13] ( ) 9 Harman EM, et al. Chest 1982;82: CT 11 Wahlen CH, et al. Obes Surg 2001;11: [28] Shinohara [3] 13 Armellini F, et al. Obes Res 1997;5: Davies RJO, et al. Eur Respir J 1990;3: Shelton KE, et al. Am Rev Respir Dis 1993;148: Mortimore IL, et al. Am J Respir Crit Care Med 1998;157: 8 Karason K, et al. Arch Intern Med 2000;160: National Institutes of Health. Obes Surg 1991;1: Lohman TG, et al. Anthropometric standardization reference manual. Champagne, IL: Human Kinetics Books, American Thoracic Society. Am J Respir Crit Care Med 1995; 2: Vilijanen AA, et al. Scand J Clin Lab Invest Suppl 1982;42:5 20 OSAS 17 Meoli AL, et al. Sleep 2001;24: OSAS 18 Johns MW. Sleep 1991;14: [8] 1 22 Sher AE, et al. Chest 1995;19: [29] OSAS 19 Fredberg JJ, et al. J Appl Physiol 1980;48: Brooks LJ, et al. J Appl Physiol 1984;57: Martin SE, et al. Eur Respir J 1997;10: Rivlin J, et al. Am Rev Respir Dis 1984;129: Bradley TD, et al. N Engl J Med 1986;315: CHEST

7 25 Brown IG, et al. J Appl Physiol 1986;61: Suratt PM, et al. Am Rev Respir Dis 1983;127: Haponik EF, et al. Am Rev Respir Dis 1983;127: Enzi G, et al. Am J Clin Nutr 1986;44: Busetto L, et al. Int J Obes 2000;24: Benumof JL. J Clin Anesth 2001;13: CHEST 2005;128: CHEST 253 CHEST B. Anti-topoisomerase 1 (SCL-70). The patient has progressive dyspnea and near syncope, with a palpable and audibly accentuated P2 on auscultation (suggesting pulmonary hypertension). These findings are accompanied by basal crackles with roentgenographic evidence of interstitial lung disease and periungual telangiectasias. Importantly, there are also symptoms of esophageal reflux and symptomatic Raynaud s phenomenon; the patient has also developed progressive renal failure requiring dialysis. This constellation of historical features, symptoms, and current findings is strongly suggestive of progressive systemic sclerosis (scleroderma). The serum anti-topoisomerase test (also known as SCL-70) is highly specific for progressive systemic sclerosis (PSS). In a recent series, the incidence of false positive results was 0.36% (1 of 264); the test yielded a true positive result in 26% of patients. In this patient the SCL-70 was 1:640, accompanied by a modestly positive antinuclear antibody. Some patients will present with a limited form of PSS known as CREST (Calcinosis, Raynaud s phenomenon, Esophageal dysmotility, Sclerodactyly, Telangiectasia), which may be accompanied by pulmonary hypertension (even more commonly than with diffuse disease) and/or interstitial lung disease. In terms of diagnostic utility, the skin biopsy from non-sun-exposed areas is useful in the evaluation of patients for systemic lupus erythematosus, which is highly unlikely in this patient. In fact, some of the skin changes noted, such as nail pitting, are attributable to the patient s long-standing psoriasis, rather than to the rheumatoid latex agglutination test, which though possibly positive in such a patient, is quite non-specific. Renal biopsy, which might provide useful histologic information, is not indicated in this frail elderly man who already has end-stage renal disease requiring dialytic therapy. The open lung biopsy would not yield specific results; the presence of severe pulmonary hypertension makes transbronchial lung biopsy risky. 224