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NON INVASIVE VENTILATION IN OBESE HYPOVENTILATION SYNDROME: CPAP versus BIPAP?. Antonio M. Esquinas MD, PhD, FCCP, Internacional Fellow AARC Intensive Care  and Non Invasive Ventilatory Unit Hospital Morales Meseguer. Murcia, Spain

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slide1

NON INVASIVE VENTILATION IN OBESE HYPOVENTILATION SYNDROME:

CPAP versus BIPAP?

Antonio M. Esquinas MD, PhD, FCCP, Internacional Fellow AARC

IntensiveCare and Non Invasive Ventilatory Unit

Hospital Morales Meseguer.

Murcia, Spain

Director  International School of Non-invasivemechanicalVentilation

President International Association of NIV and Ibero American  Association of  Bioethics in NIV

antmesquinas@gmail.com

slide2

Reasonsfordecisions

  • Key determinants
  • OHS-Pathophysiologydeterminants
  • Interactions OHS-CPAP-BIPAP
  • Determinantsinteractions: keymethodologyaspects
  • Integration CPAP and BIPAP mode in OHS diseases
  • Summary CPAP-BIPAP results
  • Strategy CPAP-keyfactors
  • Strategy BIPAP-keyfactors
  • Recommendationsforclinicalpracticedecisions
slide3

Key aspect:

OHS

Health

Care

Resources

CPAP vs BiPAP

OHS-

slide5

Key aspects

Obesity

Consequences

CPAP vs BiPAP

OHS-

slide6

Key aspect:

OHS AND OSA

Prevalence-2

CPAP vs BiPAP

OHS-

slide8

Key aspect:

OHS, OSA

COPD, Obesity,

Overlap

Diseases

Clinical, methodology

implications

CPAP vs BiPAP

OHS-

COPD

Obesity Hypoventilation

Obese

OSA

obesity mechanism lung disease
Obesity-Mechanism-Lungdisease

Key aspect:

OHS

Mechanisms

CPAP vs BiPAP

OHS-

differences normal obesity and hypoventilation
Differences: normal, obesity and hypoventilation

Key aspect:

OHS

Volume

Failure:

Pathways

CPAP vs BiPAP

OHS-

slide13

Key aspect:

OHS

Lung-effects

CPAP vs BiPAP

OHS-

slide15

Key aspect:

Obesity-OHS

Hypoxemiaduring

CPAP therapy

CPAP vs BiPAP

OHS-

slide17

Key aspect:

SummaryStudies

OHS

Prevalence-1

CPAP vs BiPAP

OHS-

slide18

Key aspect:

OHS

Arterial

Blood

Gases

Response-2

CPAP vs BiPAP

OHS-

slide19

Key aspect:

OHS

Arterial

Sleep

Parameters-3

CPAP vs BiPAP

OHS-

NPPV-Short-term and long term positive airway pressure therapy improve AHI and oxygen saturation during Sleep in OHS

slide20

NPPV-Short-term and long term positive airway pressure therapy on Pulmonary Function

Key aspect:

OHS

PulmonaryFunction-4

CPAP vs BiPAP

OHS-

slide21

NPPV-Short-term and long term positive airway pressure therapy improve % TST response with SpO2 in OHS

Key aspect:

OHS

%, TST response-5

SpO <90%

CPAP vs BiPAP

OHS-

slide22

Summary

Results -1

CPAP vs BiPAP

OHS-1

slide23

Summary

Results -2

CPAP vs BiPAP

OHS-2

slide24

Summary

Results -3

CPAP vs BiPAP

OHS-3

slide26

Key aspect:

OHS

Short and Long Term

Effects-2

CPAP vs BiPAP

OHS-

slide27

Key aspect:

OHS

Survival

Months

(18 months)

CPAP vs BiPAP

OHS-

Months after diagnosis of OHS

slide29

Factors influencing long-term survival in OHS

Key aspect:

Obesity-OHS

Long-termOutcome

OHS-5 (6 months)

Relativerisk of

death

CPAP vs BiPAP

OHS-

slide32

Key aspect:

OHS

Initialtherapy,

Acute, chronic

Situations

Ph/pCO2 trends

CPAP vs BiPAP

OHS-

slide35

Key aspect:

  • Inspiratory
  • Muscle
  • Activite-
  • Methodology-2
  • Pressure-time
  • products of diaphragm
  • OHS
  • OSA
  • Simple Obese
  • CPAP vs BiPAP
  • OHS-

OHS

OSA

Obese

OHS

OSA

Obese

slide37

Key aspect:

BackupRespiratoryRatefactor

CPAP vs BiPAP

OHS-

slide38

Key aspect:

Backup

Respiratory

Rate factor-3

CPAP vs BiPAP

OHS-

Case A=central apnea-hypopnea Case B=Mixed apnea-hypopnea

(No. of events/h)

(No. of events/h)

BURR: Backup Respiratory Rate

slide40

Inadequate adherence IPAP therapy

Inadequate PAP titration

Sleep disordered breathing other than OSA

(central hypoventilation)

Associated respiratory disease

(COPD, interstitial lung disease)

Metabolic alcalosis ( ie; due to high doses of loop diuretics)

Key aspect:

Obesity-OHS

Hypercapnic

Failure

afterPAP therapy

CPAP vs BiPAP

OHS-

slide42

Key aspect:

OHS

Interface

CPAP vs BiPAP

OHS-

slide43

Acute Hypercapnic Respiratory Failure

Interface- clinical-technical factors

slide44

Key aspect:

OHS

Compliance

And non compliance

CPAP vs BiPAP

OHS-

slide45

Summary and conclusions

forpracticaldecisions

OHS

CPAP versus BIPAP

slide46

Use of Health care resources

1-Obesity

It is a global disease. Increasing prevalence of OHS-OSA overlap

2-OHS

3-Overlap disease associations

OSA (*) predominat failure during sleep), OHS, COPD, CHF

(*) comorbidities ( cardiovascular)

Clinical- Methodology

Lung mechanics-Volume –Failure-Pathways-Expiratory reserve

Implications-Initial therapy

Acute (non PSG study) Chronic ( PSG study)

Situations

Hypoxemic------------------------------------------------------------------------------------------pH/pCO2 trends

slide47

Situations

Hypoxemic---------------------------------------Ph/pCO2 trends

1

(OSA-OHS= Acute hypercapnic during Sleep)

(CO3h trends)

2

OHS= Awake daytime hypercapnic

Upper airways compromise-Sleep

Hypercapnic mechanisms

Leptin-factor

PCO2 trends-follow up

slide48

NPPV-Interface-Pressure positive selection

Goals theory

[Gas exchange, Sleep parameters, Pulmonary function, TST SatO2 response]

CPAP-------------------------------------------------------------------------------------BiPAP

Hypoxemic Hypoxemic-hypercapnic

O2 therapy

hypercapnic

2-Respiratory breathing patterns

3-Apnea –hypopnea limitation--- (Back up respiratory rate, ST mode)

Noncompliance Compliance

Hypercapnic failure after IPAP strategy

Low VT?

Consider AVAPS

Short-term Long term effects

Mortality