Obesity Hypoventilation Syndrome
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1 Obesity Hypoventilation Syndrome Teeradej Kuptanon, MD Division of Pediatric Pulmonology, Ramathibodi Hospital, Mahidol University
2 PP; เด กหญ งไทย อาย 8 ป กทม. ประว ต จาก มารดา CC หายใจหอบเหน อยตอนกลางค นมากข นมา2 ค น PI อาย 3-4 ป เร มกรน อาย 6 ป กรนมากข นเร อย ๆ กรนด งมาก ขนาดป ดประต ห องย งได ย นเส ยงกรน หายใจ แรงท กค น บางคร งม หายใจเฮ อกมาใหม เปล ยน ท าไม หายนอนกรน
3 2-3 เด อนก อนมาโรงพยาบาล กรนด งมากข น หย ดหายใจเป นช วง ๆ ค นละหลายคร ง ด ปากเข ยวซ ด บางคร ง กลางว นง วงมาก 2-3 ว นก อนมาโรงพยาบาล หายใจล าบากมากข น กรนด งข นอ ก เข ยวบ อยข น ปากเข ยว ต วเข ยวมารดา จ ง พามาโรงพยาบาล
4 PE: T 37 o C, 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 caries nose; swollen nasal turbinate
5 Heart; normal S1 S2, no murmur, equally pulses all extremities Lungs no retraction. breath sound ฟ งไม ค อยได ย นเพราะchest wall หนาจากความอ วน ABD: soft, not distended, liver&spleen-not palpable EXT.: no rash, BCG+
6 แพทย ร บต วไว ในโรงพยาบาล เน องจาก ขณะท เด กนอนหล บ SpO drop 2 เหล อ 80-85% จ งให oxygen ผ าน nasal canula 4 LPM SpO ส งข นเป น 95-97% 2
7 หล งจากให oxygen และเด กหล บไป 3 ช วโมง พยาบาลส งเกตว าเด กเข ยว ว ด oxygen saturation ได ข น ๆ ลง ๆ อย ระหว าง 50% ถ ง 80% พยายามเขย าต ว เพ อปล กแต เด กไม ยอมต น นอนหล บสน ท ม เส ยง กรนด งมาก จ ดท านอนให เป นท าตะแคงก ไม ด ข น SpO ย งต าตลอด อย ระหว าง 50% -80% เพ ม oxygen 2 ก ไม ด ข น
8 CO2 Central chemorecepter PaO2 Peripheral chemorecepter (carotid bodies)
9 CO 2 Narcosis
10 CO2 Central chemorecepter PaO2 Peripheral chemorecepter (carotid bodies)
11 CO2 Central chemorecepter PaO2 Oxygen theraphy Peripheral chemorecepter (carotid bodies)
12 Charles Dickens 1836 The Pickwick papers
13 Undiagnosed 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
14 Definition BMI > 30 kg/m 2 Daytime hypercapnia Sleep disorder breathing
15 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
16 Pathophysiology 1. Leptin resistance 2. Increase mechanical load 3. Sleep disorder breathing
17 Obesity Leptin resistance Increased mechanical load and weak respiratory muscles OSA Upper airway resistance Acute hypercapnia during sleep Blunted ventilatory response Increased serum bicarbonate Chronic hypercapnia Mokhlesi, B et al., Recent Advances in Obesity Hypoventilation Syndrome, Chest
18 Blood Brain Barrier
19 Symptoms & Signs History Snore Dyspnea Apnea Morning headache Cor-pulmonal Medication Physical examination Plethoric obese Somnolent Crowded oropharynx Rapid shallow breathing Increase P2
20 Laboratory Arterial Blood Gas Serum Bicarbonate Pulmonary function test ( Restrictive lung ) CBC, CXR, EKG, Echocardiogram Thyroid function Sleep study
21 Interesting case After intubation TPRC TPRC
22 LABORATORY 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 , ph6.0, prot-trace, glu-ve, WBC 3-5, RBC 0-1 ABG; ph 7.32, pco2 70, HCO 3 37, po2 54.1
23 Weight reduction Treatment Positive airway pressure Oxygen Medication Bariatric surgery Tracheostomy
24 Hypoventilation P A O 2 = (FiO 2 x 713) - PaCO 2 R O 2 CO 2 P A O 2 P a CO 2
25 Noninvasive positive pressure ventilation Objectives Relieve upper airway obstruction Increase alveolar ventilation Setting Local expertise Staff familiar Follow up
26 NIPPV SYSTEM เคร องช วยหายใจ Corrugated tube Exhalation port หน ากาก สายร ดหน ากาก
27 Nasal mask Full face mask
28 Contraindications to noninvasive positive pressure ventilation Hemodynamic instability or unstable cardiac arrhythmia Inability to protect airway adequately clear secretions
29 Pressure Titration CPAP increase pressure until Eradicate apnea, hypopnea, snoring, desaturation BiPAP EPAP Eradicate apnea IPAP Eradicate hypopnea, snoring, desaturation
30 CPAP usually not more than 13 cmh 2 O BiPAP pressure difference IPAP/EPAP at least 6 cmh 2 O not more than 15 cmh 2 O Back up rate ~ 20 times/min Dement WC, et al. Brain Respiratory, 1974.
31 BiPAP setting IPAP 10 EPAP 4 Hypopnea IPAP 11 EPAP 4 Apnea IPAP 12 EPAP 5 Pressure Time
32 Clinical features suggestive of NIPPV failure Poor tolerance of the interface Lack of improvement in tachynea and dyspnea Increase use of accessory muscles with impending respiratory failure Hypotension or bradycardia Persistent and refractory hypoxemia PH persistently less than 7.25 or lack of improvement in hypercapnia after 1-2 hours
33 Medications Progesterone Almitrine Acetazolamide Leptin
34 Follow up ABG Serum Bicarbonate
35 Summary Obesity hypoventilation syndrome CO2 Narcosis NIPPV is the treatment of choice in acute and chronic hypercapnic respiratory falure in OHS patients Multidisciplinary approach Doctor, Nurse, Emergency ward, IPD, ICU
(To be filled by the treating physician)
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