Impaired Objective Daytime Vigilance in Obesity-Hypoventilation Syndrome: Impact of Noninvasive Ventilation

doi:10.1378/chest.06-1159

Chest

Volume 131, Issue 1, January 2007, Pages 148-155

https://doi.org/10.1378/chest.06-1159 Get rights and content

Abstract

Background:Obesity-hypoventilation syndrome (OHS) is efficiently treated by noninvasive ventilation (NIV). Sleep respiratory disturbances, reduced ventilatory drive, and excessive daytime sleepiness (EDS) are commonly reported, but their relationships remain unclear.

Objectives:To characterize sleep breathing disorders encountered in patients with OHS, to compare low and normal CO₂responders in terms of sleep abnormalities, subjective and objective measures of EDS, and to measure the changes induced by NIV on these parameters.

Methods:At baseline and after 5 nights of NIV, 15 consecutive patients (mean [± SD] age, 55 ± 9 years; mean body mass index, 38.7 ± 6.1 kg/m²; Paco₂, 47.3 ± 2.3 mm Hg) prospectively underwent polysomnography, CO₂ventilatory response testing, Epworth sleepiness scale scoring, and the Oxford Sleep Resistance (OSLER) test, which is an objective vigilance test.

Results:OHS patients exhibited obstructive sleep apnea syndrome (mean apnea-hypopnea index, 62 ± 32 events per hour) and rapid eye movement (REM) sleep hypoventilation (mean REM sleep time, 35 ± 33%). Baseline CO₂sensitivity was significantly related to the proportion of hypoventilation during REM sleep (r= 0.54; p = 0.037). Six patients showed abnormal sleep latencies during the OSLER test (71% of the low CO₂responders vs 14% of the normal CO₂responders). Low CO₂responders exhibited significantly shorter sleep latencies during the OSLER test (23 ± 14 vs 37 ± 8 min, respectively; p = 0.05). Using NIV, diurnal blood gas levels were improved and REM sleep hypoventilation were suppressed. Objective sleepiness was improved in low CO₂responders (p = 0.04).

Conclusion:In OHS patients, the lower the daytime CO₂response, the higher the proportion of REM sleep hypoventilation and daytime sleepiness. Short-term therapy with NIV improves all of these parameters.

Section snippets

Patients

Women or men, between 20 and 65 years of age, presenting with a body mass index (BMI) of > 32 kg/m²and daytime hypoventilation (ie, Paco₂, > 45 mm Hg) in the absence of other known causes of chronic hypoventilation (eg, COPD [FEV₁/vital capacity ratio, < 65%] or hypothyroidism) were eligible for the study. The study was approved by the hospital Ethics Committee, and patients gave written informed consent.

Study Design

A diagnosis of OHS was established according to the diurnal Paco₂and pulmonary function

Baseline Anthropometric, Functional, Sleep, and Vigilance Data

Fifteen consecutive patients (10 men), with a mean age of 55 ± 9 years were prospectively included (Table 1, Table 2, Table 3). They were morbidly obese, had moderate-to-severe daytime hypercapnia without abnormal ventilatory function. They presented with a combination of OSAS (ie, apnea-hypopnea index [AHI], 62 ± 32 events per hour of sleep) and REM hypoventilation. The average sleep time spent in hypoventilation exceeded one third of REM sleep (mean duration, 35 ± 33% [corresponding to a mean

Discussion

Our study is the first to have assessed in the same OHS individuals different types of sleep respiratory abnormalities, ventilatory responses to CO₂, and both subjective and objective measures of sleepiness at baseline and when using NIV. Awake ventilatory responses to CO₂were significantly related to the proportion of hypoventilation during REM sleep. The lower the CO₂ventilatory responses, the higher the percentage of REM sleep spent in hypoventilation. Those patients with lower responses to

Conclusion

In OHS patients, impairment in daytime ventilatory responses to CO₂was associated with the amount of REM sleep hypoventilation and the occurrence of daytime sleepiness. We have now demonstrated that therapy with NIV also improves objective vigilance in the subgroup of OHS patients who demonstrate a high proportion of REM hypoventilation and low CO₂responses during the daytime.

Acknowledgments

Thanks to N. Arnol and C. Deschaux for statistical analysis.

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Cited by (119)

Severity stages of obesity-related breathing disorders – a cross-sectional cohort study
2022, Sleep Medicine
There is a general underappreciation of the spectrum of obesity-related breathing disorders and their consequences. We therefore compared characteristics of obese patients with eucapnic obstructive sleep apnea (OSA), OSA with obesity-related sleep hypoventilation (ORSH) or obesity hypoventilation syndrome (OHS) to identify the major determinants of hypoventilation.
In this prospective, diagnostic study (NCT04570540), obese patients with OSA, ORSH or OHS were characterized applying polysomnography with transcutaneous capnometry, blood gas analyses, bodyplethysmography and measurement of hypercapnic ventilatory response (HCVR). Pathophysiological variables known to contribute to hypoventilation and differing significantly between the groups were specified as potential independent variables in a multivariable logistic regression to identify major determinants of hypoventilation.
Twenty, 43 and 19 patients were in the OSA, ORSH and OHS group, respectively. BMI was significantly lower in OSA as compared to OHS. The extent of SRBD was significantly higher in OHS as compared to OSA or ORSH. Patients with ORSH or OHS showed a significantly decreased forced expiratory volume in 1 s and forced vital capacity compared to OSA. HCVR was significantly lower in OHS and identified as the major determinant of hypoventilation in a multivariable logistic regression (Nagelkerke R² = 0.346, p = 0.050, odds ratio (95%-confidence interval) 0.129 (0.017–1.004)).
Although there were differences in BMI, respiratory mechanics and severity of upper airway obstruction between groups, our data support HCVR as the major determinant of obesity-associated hypoventilation.
Noninvasive ventilatory support in morbid obesity
2021, Pulmonology
In the conventional management of the morbidly obese that normalizes the apnea-hypopnea index (AHI), CO2 levels often remain elevated.
A retrospective review of morbidly obese patients using volume preset settings up to 1800 ml to positive inspiratory pressures (PIPs) of 25–55 cm H2O, or pressure control at 25–50 cm H2O pressure via noninvasive interfaces up to continuously (CNVS).
Twenty-six patients, mean 55.6 ± 14.8 years of age, weight 108–229 kg, mean BMI 56.1 (35.5–77) kg/m², mean AHI 69.0 ± 24.9, depended on up to CNVS for 3 weeks to up to 66 years. There were eleven extubations and seven decannulations to CNVS despite failure to pass spontaneous breathing trials. Thirteen were CNVS dependent for 92.2 patient-years with little to no ventilator free breathing ability (VFBA). Six used NVS from 10 to 23 h a day, and others only for sleep. Fifteen patients with cough peak flows (CPF) less than 270 L/m had access to mechanical insufflation-exsufflation (MIE) in the peri-extubation/decannulation period and long-term. The daytime end-tidal (Et)CO2 of 14 who were placed on sleep NVS without extubation or decannulation to it decreased from mean EtCO2 61.0 ± 9.3–38.5 ± 3.6 mm Hg and AHI normalized to 2.2. Blood gas levels were normal while using NVS/CNVS. Pre-intubation PaCO2 levels, when measured, were as high as 183 mm Hg before extubation to CNVS.
Ventilator unweanable morbidly obese patients can be safely extubated/decannulated and maintained indefinitely using up to CNVS rather than resort to tracheotomies.
Variation in ventilatory response to CO<inf>2</inf> in patients treated by non-invasive ventilation
2021, Revue des Maladies Respiratoires
Les mécanismes d’amélioration clinique et gazométrique des patients mis sous ventilation non invasive (VNI) avec un syndrome obésité hypoventilation (SOH) ou une broncho-pneumopathie chronique obstructive (BPCO) sont multiples. L’objectif de ce travail a été de mettre en place une étude pilote permettant d’évaluer la modification potentielle de la sensibilité des centres respiratoires au CO₂ chez des patients BPCO et SOH nouvellement appareillés par VNI.
Nous avons évalué la sensibilité des centres respiratoires au CO₂ par le test de Read chez 3 patients BPCO et 3 patients SOH nouvellement appareillés par VNI puis à 3 mois. Nous avons comparé leurs résultats à ceux de 6 sujets contrôles.
Tous les patients inclus avaient des réponses ventilatoires au CO₂ altérées avec des pentes inférieures à 1 L.min⁻¹.mmHg⁻¹. Le coefficient de variation moyen des deux mesures était significativement plus élevé chez les patients que chez les sujets sains (p = 0,007). Les patients améliorant leur pente de sensibilité au CO₂ étaient les plus observants pour la VNI.
Ce travail a mis en évidence des variations significatives de la réponse ventilatoire à l’hypercapnie chez les patients SOH ou BPCO après traitement par VNI. La signification de ces variations mérite d’être étudiée.
There are many mechanisms for improving the clinical and blood gas status of patients with the obesity hypoventilation syndrome (OHS) or chronic obstructive pulmonary disease (COPD) by non-invasive ventilation (NIV) at home. Our objective was to set up a pilot study to evaluate the potential modification of the sensitivity of the respiratory centers to CO₂ by NIV in paired new COPD and OHS patients.
We assessed the sensitivity of the respiratory centers to CO₂ by the Read method in 3 COPD patients and 3 OHS patients newly treated by NIV and again 3 months later. We compared their results to those of 6 control subjects.
All the patients included had altered ventilatory responses to CO₂ with slopes of less of than 1 L.min^-1.mmHg^-1. Mean coefficients of variation were significantly higher in patients than in healthy subjects (P = 0.007). Patients who improved their CO₂ sensitivity slope were those most observant of NIV.
This work showed significant changes in the ventilatory response to hypercapnia in patients with either OHS or COPD after NIV therapy. The significance of these changes deserves to be studied.
Obesity Hypoventilation Syndrome
2020, Neurological Modulation of Sleep: Mechanisms and Function of Sleep Health
The development of hypercapnic respiratory failure due to obesity alone—called the obesity hypoventilation syndrome—is associated with high morbidity and mortality. Yet, it is also a disorder which is commonly misdiagnosed or overlooked even by experienced clinicians. As a consequence, people with obesity hypoventilation experience frequent hospitalizations, poor quality of life, and social deprivation not only compared to the general population but also to those with eucapnic obesity. Factors contributing to this disorder are complex and extend beyond obesity itself. Effective treatment of sleep disordered breathing reverses daytime hypercapnia and improves symptoms in the majority of patients. However, even when therapy is instituted, mortality exceeds that seen in patients with obstructive sleep apnea alone, usually related to cardiovascular disease. Consequently, long-term management of obesity hypoventilation needs to address not just hypoventilation but also the obesity aspects of this disorder.
Cardiovascular, neurological, and inflammatory complications of obesity hypoventilation syndrome
2020, Obesity Hypoventilation Syndrome: From Physiologic Principles to Clinical Practice
Obesity hypoventilation syndrome (OHS) is a systemic disease with negative consequences that extend beyond the respiratory system. These patients have a high prevalence of cardiovascular disease, pulmonary hypertension, neurocognitive dysfunction, hypersomnia, metabolic disorders, and elevated inflammatory markers. They usually have significant functional limitations despite normal cardiac index with evidence suggesting deranged hemodynamic profile as a major cause. Other factors that contribute to this problem are obesity-related heart failure with preserved ejection fraction, right ventricular overload, and left ventricular disease. Positive airway pressure therapy can improve gas exchange abnormalities, hemodynamic repercussions, and functional capacity. The challenge is a timely diagnosis that requires a high index of suspicion. It is still an underdiagnosed disease.
Positive airway pressure II: Settings and outcomes
2020, Obesity Hypoventilation Syndrome: From Physiologic Principles to Clinical Practice
The optimal mode of positive airway pressure for patients with obesity hypoventilation syndrome (OHS) has been the topic of some debate since the 1980s. People with OHS constitute a significant proportion of patients enrolled in home ventilation programs using bilevel (BPAP) therapy, even though continuous positive airway pressure (CPAP) corrects sleep-disordered breathing and improves awake gas exchange in many of those with concomitant OSA. The modes of BPAP ventilation available to clinicians have grown in recent years, while evidence around who will benefit from them and under what circumstances remains limited. Studies evaluating PAP therapy have primarily focused on patients with stable disease, although at least a third will present with acutely decompensated disease. Treatment considerations regarding PAP need to encompass the timing of intervention, response to therapy, and the longer-term impact on patient outcomes. We need to gain a better understanding of the different OHS phenotypes beyond the presence or absence of OSA and how these traits influence the response to various PAP therapies.

View all citing articles on Scopus

This work was supported by grants from SAIME Company (Savigny le Temple, France), a subsidiary of RESMED group and COMARES.

The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

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Chest

Original ResearchImpaired Objective Daytime Vigilance in Obesity-Hypoventilation Syndrome: Impact of Noninvasive Ventilation

Abstract

Section snippets

Patients

Study Design

Baseline Anthropometric, Functional, Sleep, and Vigilance Data

Discussion

Conclusion

Acknowledgments

Am J Med

Am J Med

Chest

Chest

Chest

Chest

Chest

Chest

Chest

Respir Physiol

Chest

Respir Med

Chest

Short-term and long-term effects of nasal intermittent positive pressure ventilation in patients with obesity-hypoventilation syndrome

Chest

A behavioural test to assess daytime sleepiness in obstructive sleep apnoea

J Sleep Res

Analysis of error profiles occurring during the OSLER test: a sensitive mean of detecting fluctuations in vigilance in patients with obstructive sleep apnea syndrome

Am J Respir Crit Care Med

A manual of standardized terminology, techniques and scoring system for sleep stages in human subjects

US Governement Printing Office

Sleep

Original Research
Impaired Objective Daytime Vigilance in Obesity-Hypoventilation Syndrome: Impact of Noninvasive Ventilation