Respiratory Complications of Obesity. Diana Wilson, M.D. ACP Educational Session September 16, 2017

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1 Respiratory Complications of Obesity Diana Wilson, M.D. ACP Educational Session September 16,

2 Prevalence of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2011 Prevalence estimates reflect BRFSS methodological changes started in These estimates should not be compared to prevalence estimates before *Sample size <50 or the relative standard error (dividing the standard error by the prevalence) 30%.

3 Prevalence of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2012 Prevalence estimates reflect BRFSS methodological changes started in These estimates should not be compared to prevalence estimates before *Sample size <50 or the relative standard error (dividing the standard error by the prevalence) 30%.

4 Prevalence of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2013 Prevalence estimates reflect BRFSS methodological changes started in These estimates should not be compared to prevalence estimates before *Sample size <50 or the relative standard error (dividing the standard error by the prevalence) 30%.

5 Prevalence of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2014 Prevalence estimates reflect BRFSS methodological changes started in These estimates should not be compared to prevalence estimates before *Sample size <50 or the relative standard error (dividing the standard error by the prevalence) 30%.

6 Prevalence of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2015 Prevalence estimates reflect BRFSS methodological changes started in These estimates should not be compared to prevalence estimates before *Sample size <50 or the relative standard error (dividing the standard error by the prevalence) 30%.

7 Prevalence of Self-Reported Obesity Among U.S. Adults by State and Territory, BRFSS, 2016 Prevalence estimates reflect BRFSS methodological changes started in These estimates should not be compared to prevalence estimates before *Sample size <50 or the relative standard error (dividing the standard error by the prevalence) 30%.

8 8

9 Outline Impact of obesity on respiratory mechanics Impact of obesity on lung volumes/spirometry Impact of obesity on gas exchange Obesity hypoventilation syndrome: What we know, we don t know Perioperative considerations in the obese patient 9

10 OBESITY RELATED CHANGES IN PULMONARY PHYSIOLOGY Increased work of breathing Increased airway resistance Tendency to breathe at low lung volumes which increases airway resistance Reduced respiratory system compliance Restrictive effects of mass loading on chest wall Increased pleural pressures Low end expiratory volumes Expiratory flow limitation Gas trapping due to early airway closure Intrinsic PEEP VQ mismatching J Thorac Dis 2015;7(5):

11 Pulmonary Mechanics in the Obese Patient Reduced respiratory system compliance as much as 66% Reduced compliance of the chest wall Reduced distensibility of extrapulmonary structures Reduced compliance of the lung Increased pulmonary blood volume, increased closure of dependent airways Influenced by BMI Influenced by body fat distribution Influenced by body position Clin Chest Med September ; 30(3): 11

12 Combined lung chest wall compliance Lung compliance Chest wall compliance Anesthesia & Analgesia. 87(3): ,

13 Lung volumes a review 13

14 Jones Chest

15 Jones Chest

16 O Donnell, Pulmonary Medicine

17 O Donnell, Pulmonary Medicine

18 18

19 Sin, Arch Intern Med. 2002;162(13): 19

20 If Not Obstruction, What Drives Dyspnea? 20

21 Dyspnea Not Driven By Deconditioning Babb, et al.am J Respir Crit Care Med Vol

22 22

23 Oxygen Cost of Breathing Not Deconditioning Babb, et al.am J Respir Crit Care Med Vol

24 Oxygen Cost of Breathing Before and after Weight Loss Int J Obes. 2016; 40(6) 24

25 Sood,Clin Chest Med

26 Obesity And Gas Exchange No reduction in DLCO (increased) Most studies show normal or mild reduction in PaO2 Most studies demonstrate normal or mildly increased CO2 levels Studies vary by Inclusion criteria (BMI, etc.) Awake or anesthetized Waist hip ratio Body position Primarily driven by VQ mismatch 27

27 28

28 Anesthetized A-a O2 PCO2 Anesthesia & Analgesia. 87(3): , September

29 CHEST , DOI: ( /chest ) Figure 1

30 CHEST , DOI: ( /chest ) Figure 2

31 CHEST , DOI: ( /chest ) Figure 3

32 VQ Mismatch Lung bases relatively overperfused and underventilated Closure small airways in dependent lung zones Correlates to reduction in ERV Exacerbated by recumbency 33

33 Figure 1 CHEST 2015; 147 ( 4 ): CHEST 2015; 147 ( 4 ):

34 OHS- Definition BMI greater than 30 Hypercapnia while awake (PaCO2) 45 mm Hg Other causes of hypercapnia excluded The presence of sleep disordered breathing 35

35 Piper, AJRCCM, vol 183,

36 Why some and not others? Greater central fat distribution which may magnify all of the above Is there yet to be identified myopathic process? Is respiratory muscle performance affected by acidosis/hypoxemia? Does hypoxemia interfere with the synthesis of neurotransmitters involved in central respiratory control? Is it driven by the severity of sleep-disordered breathing, severity of oxygen desaturation/co2 retention during sleep, duration of events? Is leptin involved? Growth hormone? Inflammation? Bicarb- chicken or egg? 37

37 Pip Piper, AJRCCM, vol 183,

38 Respir Care 2015;60(5):

39 40

40 Leptin Protein produced by adipocytes Acts on hypothalamic receptors to inhibit eating Knock out mice develop OHS characteristics Decreased HCVR Increased PCO2 Decreased resp compliance Decreased lung volumes Impaired resp muscle function Leptin replacement reverses the above Piper, AJRCCM, vol 183,

41 Thank you Light-colored bars indicate simple obesity; dark gray bars indicate obesity-associated hypoventilation. Nowbar. Am J Med. 2004;116:

42 Nowbar. Am J Med. 2004;116:

43 Respir Care 2015;60(5):

44 Nowbar. Am J Med. 2004;116:

45 PULMONARY CONSIDERATIONS FOR THE OBESE PATIENT UNDERGOING SURGERY Supine positioning mechanically disadvantageous due to: Increased diaphragmatic impedance Lower lung volumes Increased upper airway collapse Impaired capacity to tolerate apneic episodes with early and more dramatic oxygen desaturation Increased incidence of OSA J Thorac Dis 2015;7(5):

46 47

47 Chung F et al Anesthesiology

48 49

49 Pre-Operative CPAP/NIPPV Ventilation strategy Positioning Anesthesia selection-regional Minimize opiates Postop location J Thorac Dis 2015;7(5):

50 Intra op PAP Recruitment maneuvers Positioning 51

51 Post op CPAP/NIPPV Monitoring SPO2/CO2 PT Positioning Mobilzation Fluid Management 52

52 53

53 Tjeertes et al. BMC Anesthesiology (2015) 15:112 54

54 Tjeertes et al. BMC Anesthesiology (2015) 15:112 55

55 Kaw, et al. Br J Anaesth 2012;109:

56 Kaw, et al. Br J Anaesth 2012;109:

57 Kaw, et al. Br J Anaesth 2012;109:

58 Kaw, et al. Br J Anaesth 2012;109:

59 Kaw, et al. Br J Anaesth 2012;109:

60 61

61 63

62 J Thorac Dis 2015;7(5):

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