Síndrome de hipoventilação da obesidade e estratégia ventilatória mais eficaz: pressão positiva contínua nas vias aéreas ou ventilação mecânica não invasiva? / Obesity Hypoventilation Syndrome and more effective ventilatory strategy: continuous positive airway pressure or non-invasive ventilation?

Considerando a Síndrome de Hipoventilação da Obesidade (SHO) como potencialmente tratável, encontra-se dificuldade em comparar ensaios clínicos devido às diferentes titulações da ventilação mecânica não invasiva (VNI) e da pressão positiva contínua nas vias aéreas (CPAP). Objetivou-se realizar uma revisão integrativa da literatura com utilização de pressão positiva como método terapêutico. Foram incluídos ensaios clínicos randomizados, utilizando CPAP comparado a VNI como tratamento. A busca ocorreu nas bases de dados PubMed e Web of Science, incluindo-se estudos publicados entre 2008 e 2017. Foram selecionados 4 artigos, dois estudos comparando CPAP e binível. Apresentaram semelhança na melhora entre os grupos. O terceiro estudo comparou com grupo controle, sendo ambas eficientes em relação ao GC com melhora na PaCO2, Bic, sintomas clínicos, parâmetros polissonográficos e efeitos secundários. O quarto estudo apresentou para Suporte de Pressão Assegurada de Volume Médio (AVAPS-AE), eficácia de CPAP e binível na redução de surtos noturnos de pressão arterial. Dessa forma observa-se similar eficácia entre ambas as estratégias, e ambas são mais eficazes quando comparadas a um grupo controle. (AU)

Asociación e interacciones de la apnea obstructiva del sueño (AOS) y del síndrome de hipoventilación obesidad (SHO) / Metabolic associations of the obstructive sleep apnea (AOS) and hypoventilation obesity syndrome

La apnea obstructiva del sueño (AOS) y el síndrome hipoventilación-obesidad (SHO) son patologías que se encuentran estrechamente asociadas a la obesidad como principal factor de riesgo, hasta un 70% de los pacientes con AOS son obesos. Ambas patologías comparten procesos fisiopatológicos comunes, donde destaca la inflamación sistémica, lo que, sumado a la hipoxia crónica intermitente y la fragmentación del sueño característicos de la AOS, aumenta considerablemente el riesgo de presentar comorbilidades metabólicas como síndrome metabólico, alteraciones en el metabolismo de la glucosa (resistencia a la insulina y diabetes mellitus tipo 2), y hígado graso metabólico. En esta revisión narrativa, se describirán los mecanismos identificados en estas asociaciones, así como la prevalencia y la evidencia sobre el tratamiento de la AOS y del SHO

Obstructive sleep apnea (OSA) and obesity-hypoventilation syndrome (OHS) are pathologies that are closely associated with obesity as the main risk factor, up to 70% of patients with OSA are obese. Both pathologies share common pathophysiological processes, where systemic inflammation stands out, which, added to the intermittent chronic hypoxia and sleep fragmentation characteristic of OSA, considerably increases the risk of presenting metabolic comorbidities such as metabolic syndrome, alterations in the metabolism of the glucose (insulin resistance and type 2 diabetes mellitus), and metabolic fatty liver. In this narrative review, the mechanisms identified in these associations will be described, as well as the prevalence and evidence on the treatment of OSA and OHS

Trastorno de hipoventilación central del sueño en pediatría: causas poco frecuentes / Central hypoventilation disorders sleep-related in pediatrics: unusual causes

Congenital central hypoventilation syndrome (CCHS) and rapid-onset obesity syndrome with hypothalamic dysfunction, hypoventilation, and autonomic dysregulation (ROHHAD) are rare causes of hypoventilation during sleep in the pediatric population. This group of disorders are characterized by the absence or decrease in the automatic control of ventilation, decreased sensitivity of chemoreceptors to CO2, causing hypoventilation during sleep and even in wakefulness, in the most severe cases. For these reasons it is important to diagnose and treat them promptly. The objective of this review is to provide current and complete literature, to be able to identify, treat and refer this group of children early, and thus reduce the complications and/or associated comorbidities in the short and long term, improving their quality of life.

El síndrome de hipoventilación central congénita (CCHS) y síndrome de obesidad de inicio rápido con disfunción hipotalámica, hipoventilación y desregulación autonómica (ROHHAD), son causas poco comunes de hipoventilación durante el sueño en la población pediátrica. Este grupo de trastornos se caracterizan por ausencia o disminución en el control automático de la ventilación, sensibilidad disminuida de los quimioreceptores al CO2, provocando hipoventilación durante el sueño e incluso en vigilia, en los casos más severos. Por estas razones es importante diagnosticarlos y tratarlos oportunamente. El objetivo de esta revisión es proporcionar literatura actual y completa, para poder identificar, tratar y referir a éste grupo de niños tempranamente, y así disminuir las complicaciones y/o comorbilidades asociadas a corto y largo plazo, mejorando su calidad de vida.

Obesity hypoventilation syndrome: a current review / Síndrome de obesidade-hipoventilação: uma revisão atual

ABSTRACT Obesity hypoventilation syndrome (OHS) is defined as the presence of obesity (body mass index ≥ 30 kg/m²) and daytime arterial hypercapnia (PaCO2 ≥ 45 mmHg) in the absence of other causes of hypoventilation. OHS is often overlooked and confused with other conditions associated with hypoventilation, particularly COPD. The recognition of OHS is important because of its high prevalence and the fact that, if left untreated, it is associated with high morbidity and mortality. In the present review, we address recent advances in the pathophysiology and management of OHS, the usefulness of determination of venous bicarbonate in screening for OHS, and diagnostic criteria for OHS that eliminate the need for polysomnography. In addition, we review advances in the treatment of OHS, including behavioral measures, and recent studies comparing the efficacy of continuous positive airway pressure with that of noninvasive ventilation.

RESUMO A síndrome de obesidade-hipoventilação (SOH) é definida pela presença de obesidade (índice de massa corpórea ≥ 30 kg/m2) e hipercapnia arterial diurna (PaCO2 ≥ 45 mmHg), na ausência de outras causas. A SOH é frequentemente negligenciada e confundida com outras patologias associadas à hipoventilação, em particular à DPOC. A importância do reconhecimento da SOH se dá por sua elevada prevalência, assim como alta morbidade e mortalidade se não tratada. Na presente revisão, abordamos os recentes avanços na fisiopatologia e no manejo da SOH. Revisamos a utilidade da medição do bicarbonato venoso como rastreamento e os critérios diagnósticos que descartam a necessidade de polissonografia. Destacamos ainda os avanços no tratamento da SOH, incluindo medidas comportamentais, e estudos recentes que comparam a eficácia do uso de pressão positiva contínua nas vias aéreas e de ventilação não invasiva.

Caracterización socio-demográfica y clínica de pacientes adultos en ventilación mecánica no invasiva domiciliaria. Ministerio de Salud. Chile / Socio-demographic and clinical characterization of adult patients in non-invasive home mechanical ventilation. Ministry of Health. Chile

Resumen Introducción: La ventilación mecánica no invasiva domiciliaria (VMNID) se entrega en Chile desde el año 2008 mediante un programa público. Incluye equipamiento y profesionales. Objetivos: 1) Caracterizar el perfil socio-demográfico y clínico del usuario adulto con VMNID y 2) Proponer mejoras de atención socio-sanitaria. Método. Estudio descriptivo transversal, mediante entrevista presencial domiciliaria y revisión de bases de datos oficiales. Muestra de 267 sujetos, ambos géneros, mayores de 20 años, con Falla Respiratoria Global Crónica (FRGC) en VMNID. En 2016 había 413 pacientes activos. Resultados: Mujeres 144 (53,9%), edad media 58,6 ± 18 años. 25,5% tienen EPOC y 24% síndrome hipoventilación obesidad, la PaCO2 promedio de ingreso al programa fue de 59 ± 11 mmHg. Ventilados desde 3,2 ± 2,4 años, por 7,6 ± 2,4 h/día. Sujetos "sin instrucción" y con "educación básica incompleta" representan el 40,7% de la muestra. 46,4% eran jubilados, 3% vive en mediaguas, 19,8% reside como allegado, 49% no contaba con pareja, el 4,8% vivía solo, 68,6% eran dependientes de oxígeno. Test de Golberg estuvo alterado en un 40%. 17,7% "posee mayor limitación, incapaz de realizar el autocuidado". Conclusiones: Nuestros pacientes tienen un deterioro socio-demográfico y clínico severo, por baja escolaridad, predominio de adultos mayores, mayor incapacidad laboral, son enfermos más graves con niveles basales de PaCO2 más altos, en comparación a estudios europeos. Los programas de VMNID deben adoptar un enfoque socio-sanitario y estar insertos en la red de salud tanto en servicio social, salud cardiovascular y mental.

Introduction: Non-invasive home mechanical ventilation (NIHMV) is delivered in Chile since 2008 throughout a public program, including equipment and professionals. Objectives: 1) Characterize the socio-demographic and clinical profile of the adult patient under NIHMV and 2) Propose improvements in social health care. Methodology: Descriptive cross-sectional study, through face-to-face home interview and review of official databases. Sample of 267 subjects, both gender, over 20 years-old, with Chronic Global Respiratory Failure (CGRF) in NIHMV. In 2016 there were 413 active patients. Results: Women 144 (53.9%), mean age 58.6 ± 18 years-old; 25.5% had COPD and 24% had a hypoventilation obesity syndrome, average PaCO2 at the time of admission to program was 59 ± 11 mmHg, they were ventilated since 3.2 ± 2.4 years, 7.6 ± 2.4 h a day. Subjects "without instruction" and with "incomplete basic education" represents 40.7% of the sample. 46.4% were retired persons; 3% lived in a precarious hut; 19.8% cohabited with relatives or close friends; 49% did not have a partner; 4.8% lived alone; 68.6% was oxygen dependent; 40% had an altered Golberg test; 17.7% "has a major limitation, unable to perform self-care". Conclusions: Our patients have a severe socio-demographic and clinical deterioration, due to low schooling level, predominance of older adults, a major incapacity for working and patients have a more severe disease with higher baseline PaCO2 levels, compared to European studies. NIHMV programs must adopt a social health approach and be inserted into the health network in social service, and cardiovascular and mental health programs.

A Case of Rapidly Developed Obesity Hypoventilation Syndrome in a Patient with Kyphoscoliosis / 수면정신생리

Obesity hypoventilation syndrome (OHS) is characterized by severe obesity, excessive daytime sleepiness, hypoxemia and hypercapnea. Because OHS mimics pulmonary hypertension or cor pulmonale, clinicians should recognize and treat this syndrome appropriately. A 58-year-old female visited the emergency room because of dyspnea. She was obese and had kyphoscoliosis. The patient also experienced snoring, recurrent choking during sleep and daytime hypersomnolence which worsened after gaining weight in the recent year. The arterial blood gas analysis showed she experienced hypoxemia and hypercapnea not only during nighttime but also daytime. We suspected OHS and the patient underwent polysomnography to confirm whether obstructive sleep apnea was present. During the polysomnography test, sleep obstructive apnea was observed and apnea-hypopnea index was 9.2/hr. The patient was treated with bilevel positive airway pressure therapy (BiPAP). After BiPAP for 4 days, hypoxemia and hypercapnia were resolved and she is currently well without BiPAP. We report a case successfully treated with clinical improvement by presuming OHS early in a patient who had typical OHS symptoms, even while having other conditions which could cause hypoventilation.

Anesthetic management of the bariatric surgery

Obesity, that is, having a body mass index (BMI) >30 kg/m2, has increased dramatically and became the most single most common preventable cause of death in South Korea. In the end, obesity results in metabolic syndrome, which includes abdominal obesity, increased triglycerides, decreased high-density lipoprotein, hypertension, and impaired glucose tolerance. Nonsurgical methods for obesity treatments include dietary therapy, exercise counseling, behavioral therapy, psychiatric therapy, and pharmacotherapy. Surgical methods for obesity treatments, laparoscopic gastric banding and Roux-en-Y gastric bypass, are commonly performed for obese patients, particularly those with a BMI of 40 kg/m2 or at BMI more than 30 kg/m2 with accompanying diseases related to metabolic syndrome such as hypertension, type 2 diabetes, hypercholesterolemia, asthma, angina, other cardiopulmonary diseases, infertility, polycystic ovary, urinary incontinence, severe arthritis, or Pickwickian syndrome. Preoperative evaluation for bariatric surgery should focus on airway management, sleep apnea history, use of a continuous positive airway pressure device, and comorbid systemic diseases. Special consideration and pharmacokinetic knowledge is needed for the choice and dose of the anesthetic agents as well as postoperative pain control, patient monitoring, fluid intake, and surgical complications. Obesity is a disease. Appropriate surgical intervention and peri-operative anesthetic care for bariatric surgery will increase the safety and satisfaction of obese patients and will finally provide a better quality of life for our society.

Obesity and sleep-related breathing disorders / 中国医学科学院学报

Obesity, with an increasing prevalence,has become one of the most common metabolic diseases. Obesity is associated with many respiratory diseases, especially sleep-related breathing disorders including obstructive sleep apnea-hypopnea syndrome, obesity hypoventilation syndrome, and overlap syndrome. This article reviews the association between obesity and these sleep-related breathing disorders.

Evaluación del paciente obeso / Evaluation of the obese patient

La obesidad es considerada una epidemia a nivel mundial y será seguida por una epidemia de diabetes. En el año 2005, más de 400 millones de adultos eran obesos en todo el mundo y este número se espera que aumente a más de 700 millones para el 2015. La obesidad es una entidad que está asociada con enfermedades crónicas, como son la diabetes mellitus tipo 2 y la enfermedad cardiovascular. Además, la obesidad puede promover el desarrollo de otros trastornos como el síndrome metabólico, la esteatosis hepática no alcohólica, la hipertensión y algunos cánceres. Aunque existe una base genética para la obesidad, el aumento en el consumo de calorías y estilos de vida poco saludables, sin actividad física, ha disparado la prevalencia de esta condición. Una intervención más eficaz para prevenir y tratar la obesidad, debe convertirse en una prioridad para el sistema de salud, que garantice un mejor pronóstico para estos individuos.

Hipoventilação relacionada ao sono / Sleep hypoventilation

Tanto SHO como as doenças neuromusculares estão relacionadas à hipoventilação durante o sono. Define-se SHO como a combinação de obesidade, hipercapnia e hipoxemia crônica durante a vigília que se agrava durante o sono. Em 90 por cento dos casos, SHO está associada à apneia obstrutiva do sono. O diagnóstico baseia-se na presença de hipoventilação diurna e hipertensão pulmonar que não são justificadas por alterações da função pulmonar. A mortalidade dos pacientes com SHO é maior que aquela de pacientes sem hipoventilação e controlados para obesidade. As doenças neuromusculares são representadas principalmente pelas distrofias musculares. A progressão para insuficiência respiratória crônica surge como consequência da fraqueza dos músculos respiratórios e da limpeza inadequada das vias aéreas, causando atelectasias e pneumonias. Quando há uma redução maior que 50 por cento da forca muscular respiratória, ocorre uma diminuição na CV. A medida do pico de fluxo da tosse < 160 L/min está associada à limpeza inadequada das vias aéreas, e, com valores em torno de 270 L/min, há indicação de uso de técnicas de tosse assistida. A apneia obstrutiva do sono geralmente agrava a hipoventilação durante o sono. O suporte pressórico não invasivo durante a noite pode aumentar a sobrevida, melhorar os sintomas e a hipoventilação diurna. Além disso, no caso de doenças neuromusculares, pode diminuir o declínio da função pulmonar. A oxigenoterapia pode ser necessária nos casos de SHO.

Sleep hypoventilation is seen in patients with neuromuscular disease, as well as in those with obesity hypoventilation syndrome (OHS), which is defined as the combination of obesity, chronic hypercapnia, and hypoxemia during wakefulness that is aggravated during sleep. In 90 percent of cases, OHS is accompanied by obstructive sleep apnea. The diagnosis of OHS is based on hypoventilation and pulmonary hypertension that cannot be explained by alterations in pulmonary function. The mortality of patients with OHS is greater than is that of obese patients without hypoventilation. The principal neuromuscular diseases associated with OHS are the muscular dystrophies. The progression to chronic respiratory failure results from respiratory muscle weakness and impaired airway secretion clearance, causing atelectasis and pneumonia. With a decrease of greater than 50 percent in respiratory muscle strength, there is a reduction in VC. Cough peak flow < 160 L/min is associated with impaired airway secretion clearance, and values near 270 L/min indicate the need for assisted cough techniques. Obstructive sleep apnea usually worsens sleep hypoventilation. Noninvasive ventilation during sleep can improve survival, symptoms, and hypoventilation during wakefulness, as well as being able to improve pulmonary function in patients with neuromuscular disease. Patients with OHS can require oxygen therapy.

La neurología en un personaje de Dickens: síndrome pickwickiano, apneas hipopneas del sueño e hipertensión intracraneal

En muchos casos, la literatura de ficción se ha adelantado a la ciencia. Charles Dickens (1812-1870) pobló su obra con un tropel de notables personajes. Como la mayoría de los grandes novelistas, le adornaban finos dotes de observación y una extraordinaria capacidad descriptiva. Uno de sus protagonistas secundarios se ganó un puesto en los anales de la medicina. El logro de esta empresa se da al presentarnos la figura de un sirviente gordo y somnoliento llamado Joe, que a pesar de tener un pequeño y breve rol en el capítulo 54 de sus “Pickwick Papers” (1836), ha trascendido al lenguaje médico diario. La cómica caricatura que caracteriza al individuo obeso, sobrevivió en el ámbito de la medicina como un caso clásico de apneas del sueño: el síndrome de Pickwick o más precisamente, el síndrome Pickwickiano. Debieron transcurrir más de 120 años para que Burwell y sus colaboradores, hallaran una explicación fisiopatológicaal fenotipo de Joe, ese “niño gordinflón, rosado y roncador con la respiración entrecortada, eternamente somnoliento”,describiendo así, la presencia del síndrome apneashipopneas del sueño e hipoventilación alveolar en el sujeto obeso. La presencia de hipertensión intracraneal es otro de sus infrecuentes componentes. Describimos una serie de cuatro pacientes

In many cases, fictional literature has preceded science. Charles Dickens (1812-1870) filled his novels with anumber of noteworthy characters. As most great novelists, he possessed fine observation skills and an extraordinary capacity for description. In fact, one of his secondary characters gained a place in the world of medicine. From the “Pickwick Papers” (1836), Joe, the overweight and lazy servant, in spite of his brief appearance in chapter 54, has transcended to become part of the physician’s every day lingo. The amusing depiction that characterizes the overweight individual, survived in the medical world as the classic case of sleep apneas, the Pickwick syndrome or more precisely, the Pickwickian syndrome. After 120 years Burwell and his collaborators found a physiopathological explanation to the phenotype of Joe, ¨that fat and red-faced, chubby, plump and wheeze boy, in a state of somnolence”, so describing the presence of sleep apneas hypopneas and alveolar hypoventilation in obese individuals. The presence of intracranial hypertension is another of its infrequent components. We described a series of 4 of such cases.

Síndrome obesidade-hipoventilação alveolar / Obesity hypoventilation syndrome

RESUMO: Os distúrbios respiratórios do sono constituem um tópico relativamente novo do conhecimento científico, cujo manejo envolve a participação de diversas Disciplinas da área Médica. Sua importância tem crescido desde a disponibilização em escala “democrática” dos recursos diagnósticos e terapêuticos que se iniciou no começo dos anos de 1980. Isso permitiu constatações sucessivas do papel do sono e dos seus distúrbios no aumento da morbidade e da mortalidade. A prevalência também tem aumentado desde os primeiros levantamentos epidemiológicos em adultos, em parte devido ao aumento dos fatores de risco, principalmente a obesidade e idade, mas também ao melhor reconhecimento de anormalidades devido ao aumento na sensibilidadedos métodos diagnósticos utilizados. As apnéias/hipopnéias do sono têm se revelado ser o mais importante e freqüente distúrbio respiratório do sono, constituindo cerca de 80 dos casos que procuram as Clínicas dedicadas a estudar as anormalidades do sono.

A Case of Severe Obesity-Hypoventilation Syndrome Treated by Bilevel Positive Airway Pressure Therapy

Obesity-Hypoventilation syndrome (OHS) is characterized by morbid obesity, hypoxia, and hypercapnea during wakefulness without parechymal lung disease or severe obstructive sleep apnea. A woman was admitted because of mental deterioration and diagnosed as OHS on the basis of obesity and hypoventilation, while awake, after ruling out other causes. By bilevel positive airway pressure (BiPAP) therapy, hypercapnea and hypoxia were resolved. We report that BiPAP can be an effective treatment for severe hypercapnea and hypoxia in OHS, which obviate the need for invasive endotracheal intubation.

El aporte de la cirugía bariátrica en el tratamiento del síndrome de Pickwick / Contribution of bariatric surgery in the treatment of Pickwick syndrome

El conjunto de alteraciones respiratorias que sufren los obesos mórbidos y que llevan a la hipoxemia e hipercapnia crónica, con poliglobulia compensatoria y falla cardíaca derecha secundaria es conocida desde hace tiempo como Síndrome de Pickwick. Su tratamiento médico es complejo y poco efectivo, siendo en la actualidad la cirugía bariátrica la que mejores resultados obtiene. En una serie de seis pacientes, con este cuadro, operados desde 1980 por el autor principal, sus resultados han sido muy satisfactorios al corregir rápida y efectivamente las graves alteraciones respiratorias presentes, corroborando lo descrito por la literatura mundial

As a matter of fat: a case of pickwickian syndrome undergoing bariatric surgery

The objective of this case report was to present a case of morbidly obese patient with Pickwikian syndrome for bariatric surgery, with specific emphasis on its clinical presentations and its anesthetic implications.

Obesidad: una epidemia del siglo XXI / Obesity: an epidemic of the 21st century

La OMS considera a la obesidad como la epidemia del siglo XXI, con alta prevalencia en la población pediátrica. La obesidad, además del sustrato biológico está ligada a factores culturales, acceso a alimentos y cambios en el modo de comer de ciertas sociedades. Salvo en un pequeño porcentaje, la obesidad no responde a una etiología única; es de origen multifactorial. No es una enfermedad en sí, pero es un factor de riesgo para numerosas patologías, tanto de la niñez como del adulto. Se describe la obsidad extrema o Síndrome de Picwick, así como algunas enfermedades que causan obesidad. Se mencionan algunos conocimientos actuales sobre fisiopatología, diagnóstico y trartamiento, así como las dificultades terapéuticas y sus frecuentes fallos en el largo plazo. Se enfatiza finalmente la importancia de la prevención y la responsabilidad del equipo de salud en la misma, especialmente en la edad pediátrica

Síndrome de Pickwick no complicado / Non-complicated pickwickian syndrome

Se presenta el caso de una paciente de 23 años con un síndrome de Pickwick no complicado. Se comentan y discuten los resultados obtenidos en el éxamen clínico, en las pruebas espirométricas y cardilógicas realizadas a una enferma con 155,4 Kg de peso. Se hacen algunas consideraciones sobre esta enfermedad y se reseña la importancia del aumento de peso y la dieta inadecuada,así como la no realización de ejercicios en todos estos casos. Se trata de una enfermedad curable y por tanto, reversible