Evaluación respiratoria y manejo de pacientes con obesidad candidatos a procedimientos quirúrgicos y cirugía bariátrica / Respiratory evaluation and management of obese patients who are candidates for surgical procedures and bariatric surgery

En el seno de la Sección de Sueño, Oxigenoterapia y Asistencia Ventilatoria de la Asociación Argentina de Medicina Respiratoria, se planteó el desarrollo de sugerencias para la exploración respiratoria del paciente con obesidad y definiciones sobre el manejo perioperatorio en cirugía bariátrica y procedimientos quirúrgicos electivos (cirugía no bariátrica). Esta iniciativa se basó en la necesidad de contar con lineamientos adaptados a la realidad local y discutida por expertos que se desempeñan en la realidad coyuntural cotidiana de nuestro país. La agenda se inició en agosto de 2020 en un grupo de revisión de la bibliografía y redacción. Revisores de diferentes provincias argentinas efectuaron una extensa valoración de la evidencia. Luego, un comité editorial realizo una revisión crítica del documento. Finalmente, todo el grupo debatió las sugerencias que se exponen como puntos clave. Este documento exhorta a cirujanos y clínicos a trabajar junto a especialistas respiratorios en la evaluación del riesgo, definición de la aptitud operatoria y corrección de trastornos funcionales y apneas del sueño. La cirugía en individuos con obesidad y la cirugía bariátrica, son procedimientos a los que se arriba luego de una evaluación exhaustiva de la situación clínica y funcional. La tarea multidisciplinaria y el tratamiento de las anormalidades detectadas pueden disminuir los riesgos perioperatorios. Pacientes con obesidad que requieren cirugía electiva con anestesia general deben ser evaluados mediante pruebas objetivas para confirmar la presencia de apneas del sueño y estar adecuadamente tratados con CPAP.

Within the Sleep, Oxygen Therapy and Ventilatory Assistance Section of the Argentine Association of Respiratory Medicine, we de velopment of recommendations for the respiratory exploration of patients with obesity and definitions on perioperative management in bariatric surgery and elective surgical procedures (surgery non bariatric). This initiative was based on the need to have guidelines adapted to the local reality and discussed by experts who work in the daily conjunctural reality of our country. The schedule was started in August 2020 in a literature review group. Reviewers from different Argentine provinces carried out an extensive assessment of the evidence. Then, an editorial committee performed a critical review of the document. Finally, the whole group discussed the suggestions that are presented as key points. This document encourages surgeons and clinicians to work close to respiratory specialists in assessing risk, defining operative competence, and revise functional disorders and sleep apnea. Surgery in obese individuals and bariatric surgery are procedures that are reached after a detailed evaluation about clinical and functional situation. The multidisciplinary team and the treatment of detected abnormalities can reduce perioperative risks. Obese patients who require elective surgery with general anesthesia should be evaluated by objective tests to confirm the presence of sleep apnea and be adequately treated with CPAP.

Patient Intolerance and Compliance with Positive Airway Pressure Treatment Outpatient Consultations Profile in a Sleep Unit

Abstract Introduction: Treatment with positive pressure may cause adverse effects. In order to know the compliance and intolerance profile, we analyzed the behaviors established by physiotherapists of a Sleep Unit. Materials and Methods: Observational, retrospective, cross-sectional study. We included patients older than 18 years with positive pressure referred to the kinesiological consultation. Results: 244 patients were evaluated during four years: 165 men (67%), age 65.7 ± 11.6 years, BMI (Body Mass Index) 31.0 ± 5.4 (kg/m2), 61% of which used fixed CPAP (Continuous Positive Airway Pressure), 29% auto-adjusting CPAP, 8% bilevel devices, 147 (60%) nasal masks, 52 (21%) oronasal masks; 37 pads (15%), and 92 (36%) thermohumidifiers. Reasons for consultation were: therapy control, 239 (61%); intolerance, 67 (17%), and calibration, 51 (13%). Compliance (hours/night) was 4.61 ± 2.1, with a percentage of nights > 4 hours of 67 ± 36%. We didn't find any difference in the com pliance of the first and the second year (4.5 vs. 5.0 hours/night) p > 0.13, but the value was higher after 600 days of therapy (p < 0.05). 141 patients (57%) showed some complications, the most frequent being leaks (19%) or intolerance to the masks (10%). 97% of the patients resolved the intolerance with 194 behaviors: explanation of how to use the mask, 94 (48%); calibration, 44 (22%); information, 45 (23%); titration, 13 (6%), and referral to the pulmonologist, 14 (7%). Conclusions: Two thirds of the patients complied with the positive pressure treatment and half of the patients showed intolerance. The specialized kinesiological consultation can contribute to the identification and resolution of difficulties that may arise during therapy.

Obstructive Sleep Apnea in Interstitial Lung Disease / 수면정신생리

Obstructive sleep apnea is a common disorder in which respiratory flow decreases or disappears despite respiratory effort due to occlusion of the upper respiratory tract during sleep. Oxidative stress and systemic inflammatory reaction induced by the obstruction cause complications such as hypertension, coronary artery disease, and diabetes and increase cancer incidence. Furthermore, in patients with interstitial lung disease, obstructive sleep apnea has a very high prevalence and is thought to have a close pathophysiological and clinical correlation. In other words, obstructive sleep apnea could be the cause or a complication of interstitial lung disease ; when these two afflictions coexist, the prognosis of the patient is worse. In patients with interstitial lung disease with obstructive sleep apnea, CPAP treatment significantly improved sleep and quality of life, as well as improved morbidity and mortality in a recent study. Therefore, early diagnosis and treatment of obstructive sleep apnea in patients with interstitial lung disease are very important, and additional studies designed to include patients with idiopathic pulmonary fibrosis as well as patients with advanced interstitial lung disease should be performed.