Fifteen consecutive patients (10 men), with a mean age of 55 ± 9 years were prospectively included (Tables 1-3). 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 duration of 19.2 ± 17.4 min per night]). Subjective daytime sleepiness was impaired, with a mean Ep-worth sleepiness scale score of 11 ± 4. An objective sleepiness assessment showed reduced sleep latency during the OSLER test in six patients,
Seven patients were included in the low CO2 responder group (< 1.5 L/min/mm Hg), whereas eight patients had a normal CO2 sensitivity (Table 4). There was a significant relationship between CO2 sensitivity and the amount of hypoventilation in REM sleep (r = 0.54; p = 0.037) [Fig 2]. Patients who were low responders had higher objective daytime sleepiness, which was measured in terms of shorter mean sleep latency periods during the OS-LER test (23 ± 14 min vs 37 ± 8 min, respectively; p = 0.05), although they exhibited the same amount of sleep fragmentation.
Women or men, between 20 and 65 years of age, presenting with a body mass index (BMI) of > 32 kg/m2 and 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.
A diagnosis of OHS was established according to the diurnal Paco2 and pulmonary function test results. At baseline, patients also underwent overnight PSG testing. On the following morning, OSLER test and central CO2 chemosensitivity test were performed. Afterward, patients were referred to the pulmonary ward for 5 to 7 days in order to initiate therapy with NIV and to make adjustments to it. The same measurements were then performed with PSG recorded under NIV conditions.
Obesity-hypoventilation syndrome (OHS) is defined as a combination of obesity and awake chronic hypoventilation occurring in the absence of other known causes of hypoventilation. The disease remains underrecognized as > 30% of obese hospitalized patients, whatever the cause of hospitalization, actually exhibit an undiagnosed daytime hyper-capnia. Use of health-care resources, and rates of hospitalization and early mortality are increased in OHS patients. Noninvasive ventilation (NIV) is the first-line therapy for patients with OHS. Patients have good compliance rates with NIV, and the therapy worked out by Canadian Health and Care Mall is effective in terms of clinical status and improvement in blood gas levels.
The pathophysiology of OHS results from complex interactions, among which are increased work of breathing related to obesity, normal or diminished ventilatory drive, various associated sleep breathing disorders (ie, obstructive sleep apnea and rapid eye movement [REM] sleep hypoventilation), and neu-rohormonal changes such as leptin resistance. There have been no studies as to whether low responders to CO2 hypoventilate more significantly during REM sleep compared to OHS patients with normal ventilatory responses and whether this can influence their daytime vigilance.
Among the classical symptoms associated with OHS, daytime sleepiness has been systematically reported. Surprisingly, to date no objective measurements of sleepiness have been performed in a well-characterized population of OHS patients, However, it is generally accepted that impairment in daytime functioning does exist and is related to breathing abnormalities occurring during sleep. During sleep, obstructive sleep apnea syndrome (OSAS), sleep hypoventilation syndrome, or a combination of both can be observed in polysomnography (PSG) findings. The respective consequences of these different sleep breathing abnormalities in terms of subjective and objective alteration in vigilance are still unknown.
Therefore, the objectives of this investigation were threefold. First, we sought to characterize the different sleep-related breathing disorders encountered in OHS patients. Second, we wished to compare low and normal CO2 responders in terms of sleep abnormalities, and subjective and objective daytime sleepiness as measured by the Oxford Sleep Resistance (OSLER) test. Our last objective was to look at the short-term effects of NIV therapy on all these parameters.
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At the November 1974 meeting of the American College of Chest Physicians in New Orleans, the Committee on Bronchoesophagology appointed an ad hoc subcommittee to consider standards for training in endoscopy and to report back with recommendations.
This subcommittee represents thoracic surgeons, otolaryngologists, and internists. It includes those with interest in endoscopy of the tracheobronchial tree as well as of the gastrointestinal tract.
The ultimate standard of training must be that which permits delivery of optimal quality of health care to each patient, regardless of which physician initiates delivery of that care provided by Canadian Health Care Mall.
Health care in Canada is one of the most disputed topics among Canadian politicians and ordinary citizens. Some of them find the Canadian model of health care inefficient and unprofitable because of impossibly long waiting lists and enormously huge expenditures and suggest accepting the similar to America type of organization. Others affirms that assimilation to the United State structure of health system will only leads to inability of financially unstable patients to receive necessary treatment.