With the increase in the global prevalence of obesity, there is a parallel rise in the proportion of obese patients admitted to intensive care units, referred for major surgery or requiring long-term ...non-invasive ventilation (NIV) at home for chronic respiratory failure. We describe the physiological effect of obesity on the respiratory system mainly in terms of respiratory mechanics, respiratory drive, and patency of the upper airways. Particular attention is given to the prevention and the clinical management of respiratory failure in obese patients with a main focus on invasive and NIV in intensive care during the perioperative period and long-term use of NIV on return home. We also address other aspects of care of obese patients, including antibiotic dosing and catheter-related infections.
Central sleep apnoea: not just one phenotype Randerath, Winfried; Baillieul, Sébastien; Tamisier, Renaud
European respiratory review,
01/2024, Letnik:
33, Številka:
171
Journal Article
Recenzirano
Odprti dostop
Recent scientific findings in the field of sleep disordered breathing have characterised a variety of phenotypes in obstructive sleep apnoea. These findings have prompted investigations aiming to ...achieve a more precise differentiation and description of the entities of central sleep apnoea (CSA). There is increasing evidence for the heterogeneity of CSA in terms of underlying aetiology, pathophysiological concepts, treatment response and outcome. Assigning patients to these phenotypes allows for the selection of individualised therapies. Major pathophysiological characteristics include loop gain, apnoeic threshold, breathing regulation and neuromuscular mechanics. Chronic heart failure is the most important underlying disease, leading to nonhypercapnic CSA based on increased loop and controller gain. Although many questions remain, this review tries to describe the current knowledge on the pathophysiology of the clinical entities. The description of prognostic aspects may guide treatment indication and the selection of pharmacotherapy and invasive options. In addition, the paper provides an update on the current understanding of adaptive servo-ventilation and its role in the treatment of CSA.
The classification of obstructive sleep apnea is on the basis of sleep study criteria that may not adequately capture disease heterogeneity. Improved phenotyping may improve prognosis prediction and ...help select therapeutic strategies.
This study used cluster analysis to investigate the clinical clusters of obstructive sleep apnea.
An ascending hierarchical cluster analysis was performed on baseline symptoms, physical examination, risk factor exposure and co-morbidities from 18,263 participants in the OSFP (French national registry of sleep apnea). The probability for criteria to be associated with a given cluster was assessed using odds ratios, determined by univariate logistic regression.
Six clusters were identified, in which patients varied considerably in age, sex, symptoms, obesity, co-morbidities and environmental risk factors. The main significant differences between clusters were minimally symptomatic versus sleepy obstructive sleep apnea patients, lean versus obese, and among obese patients different combinations of co-morbidities and environmental risk factors.
Our cluster analysis identified six distinct clusters of obstructive sleep apnea. Our findings underscore the high degree of heterogeneity that exists within obstructive sleep apnea patients regarding clinical presentation, risk factors and consequences. This may help in both research and clinical practice for validating new prevention programs, in diagnosis and in decisions regarding therapeutic strategies.
Summary Reducing cardiometabolic risk may represent an important target for effective obstructive sleep apnea (OSA) treatment. The impact of continuous positive airway pressure (CPAP), the first line ...therapy of OSA, on metabolic or inflammatory markers is still debated. A systematic literature search using several databases was performed. We provide a systematic analysis of randomized studies comparing therapeutic versus sham CPAP intervention and also include studies using a CPAP withdrawal design. We addressed the impact of CPAP on the following cardiometabolic biomarkers: 1) plasma and urine catecholamines and their metabolites that reflect sympathetic activity; 2) insulin resistance and lipid metabolism biomarkers; 3) oxidative stress, systemic and vascular inflammation biomarkers; 4) liver enzymes highlighting the association between OSA and nonalcoholic fatty liver disease (NAFLD); 5) coagulation biomarkers. The impact of CPAP on sympathetic activity is robust across studies and occurs rapidly. In contrast to sympathetic activity, the well-designed studies included in this review failed to demonstrate that CPAP alters metabolic or inflammatory markers in OSA. CPAP did not change glucose, lipids, insulin resistance levels or the ratio of patients with metabolic syndrome. In unselected OSA patients, it is not realistic to expect a clinically relevant decrease in cardiometabolic biomarkers with CPAP therapy.
Obstructive sleep apnea (OSA) is associated with cardiovascular morbidity and mortality, largely as a result of myocardial anomalies. Numerous mechanisms cause OSA-related myocardial damage. The ...majority are initiated as a result of OSA-induced, chronic, intermittent hypoxia. The most-important mechanisms that lead to myocardial damage are increased sympathetic activity, endothelial dysfunction, systemic inflammation, oxidative stress, and metabolic anomalies. All these mechanisms promote the development of hypertension, which is common in patients with OSA. Hypertensive cardiomyopathy and coronary heart disease, as well as obesity-related, diabetic, and tachycardia-induced cardiomyopathies, are also associated with OSA. Left ventricular hypertrophy, myocardial fibrosis, atrial dilatation, and left ventricular systolic and diastolic dysfunction in patients with OSA explain the association of the disease with these clinical outcomes. The gold-standard treatment for OSA, nasal continuous positive airway pressure (CPAP), might improve cardiac symptoms and hemodynamic parameters in patients with the disease. However, large clinical trials are required to improve our understanding of the cardiac consequences of OSA, and determine the effect of treatment, particularly CPAP, on myocardial damage in symptomatic patients and primary prevention of cardiovascular disorders.
ABSTRACT
It is increasingly recognized that the high prevalence of obstructive sleep apnoea (OSA), and its associated cardio‐metabolic morbidities make OSA a burden for society. Continuous positive ...airway pressure (CPAP), the gold standard treatment, needs to be used for more than 4 h/night to be effective, but suffers from relatively poor adherence. Furthermore, CPAP is likely to be more effective if combined with lifestyle changes. Thus, the remote telemonitoring (TM) of OSA patients in terms of CPAP use, signalling of device problems, following disease progression, detection of acute events and monitoring of daily physical activity is an attractive option. In the present review, we aim to summarize the recent scientific data on remote TM of OSA patients, and whether it meets expectations. We also look at how patient education and follow‐up via telemedicine is used to improve adherence and we discuss the influence of the profile of the healthcare provider. Then, we consider how TM might be extended to encompass the patient's cardio‐metabolic health in general. Lastly, we explore how TM and the deluge of data it potentially generates could be combined with electronic health records in providing personalized care and multi‐disease management to OSA patients.
Obstructive sleep apnoea (OSA) is a major health concern worldwide and adversely affects multiple organs and systems. OSA is associated with obesity in >60% of cases and is independently linked with ...the development of numerous comorbidities including hypertension, arrhythmia, stroke, coronary heart disease and metabolic dysfunction. The complex interaction between these conditions has a significant impact on patient care and mortality. The pathophysiology of cardiometabolic complications in OSA is still incompletely understood; however, the particular form of intermittent hypoxia (IH) observed in OSA, with repetitive short cycles of desaturation and re-oxygenation, probably plays a pivotal role. There is fast growing evidence that IH mediates some of its detrimental effects through adipose tissue inflammation and dysfunction. This article aims to summarise the effects of IH on adipose tissue in experimental models in a comprehensive way. Data from well-designed controlled trials are also reported with the final goal of proposing new avenues for improving phenotyping and personalised care in OSA.
Data from women (n = 305, aged 43 34; 53 years-old, BMI 44.2 40.8; 48.2 kg/m2) included in the Severe Obesity Outcome Network (SOON) cohort were analyzed (i) to evaluate collinearity between the ...different anthropometric markers, (ii) to compare the association of markers with hypertension, type 2 diabetes, obstructive sleep apnea syndrome (OSAS) and other cardiometabolic risks.
Hip, waist and neck circumferences correlated with BMI with respectively less collinearity (r = 0.70, r = 0.59 and r = 0.37, respectively, p<0.001) whereas waist-to-hip ratio was not correlated (r = 0.11, p = 0.072). Waist and neck circumferences were significantly associated with hypertension, type 2 diabetes and OSAS in univariate logistic regressions, waist-to-hip ratio with hypertension and type 2 diabetes. Hip circumference was inversely correlated with type 2 diabetes (OR 0.970 (95CI: 0.948; 0.991) p = 0.006). BMI was only linked to OSAS (OR 1.092 (95CI: 1.043; 1.143) p<0.001). Neck circumference was the only marker significantly associated with all cardiometabolic risk markers (HOMA-IR, apnea-hypopnea index, Log Triglycerides/HDL-c, alanin-aminotransferase, aspartate-aminotransferase, gammaglutamyl transpeptidase).
Neck circumference appears the most appropriate anthropometric marker to identify the fat distribution associated with high cardiometabolic risk in women with severe obesity.
Nonalcoholic fatty liver disease (NAFLD) is independently linked to cardiometabolic morbidity and mortality. Low-grade inflammation, oxidative stress and ectopic fat, common features of chronic ...obstructive pulmonary disease (COPD), might contribute to the development of NAFLD.We aimed to investigate the prevalence of NAFLD and to evaluate the relationship between various types of liver damage and COPD severity, comorbidities and circulating inflammatory cytokines. Validated noninvasive tests (FibroMax: SteatoTest, NashTest and FibroTest) were used to assess steatosis, nonalcoholic steatohepatitis (NASH) and liver fibrosis. Patients underwent an objective assessment of COPD comorbidities, including sleep studies. Biological parameters included a complete lipid profile and inflammatory markers.In COPD patients the prevalence of steatosis, NASH and fibrosis were 41.4%, 36.9% and 61.3%, respectively. In multivariate analysis, SteatoTest and FibroTest were significantly associated with sex, body mass index (BMI), untreated sleep apnoea and insulin resistance, and, in addition, COPD Global Initiative for Chronic Obstructive Lung Disease stage for SteatoTest. Patients with steatosis had higher tumour necrosis factor-α levels and those with NASH or a combination of liver damage types had raised leptin levels after adjustment for age, sex and BMI.We concluded that NAFLD is highly prevalent in COPD and might contribute to cardiometabolic comorbidities.
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