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

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

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  1. 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

  2. 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

  3. Key aspect: OHS Health Care Resources CPAP vs BiPAP OHS-

  4. ObesityHypoventilationSyndromeConsequences

  5. Key aspects Obesity Consequences CPAP vs BiPAP OHS-

  6. Key aspect: OHS AND OSA Prevalence-2 CPAP vs BiPAP OHS-

  7. OHS, OSACOPD, Obesity, OverlapDiseases

  8. Key aspect: OHS, OSA COPD, Obesity, Overlap Diseases Clinical, methodology implications CPAP vs BiPAP OHS- COPD Obesity Hypoventilation Obese OSA

  9. OHSRespiratoryFailurePathways-Influence

  10. Obesity-Mechanism-Lungdisease Key aspect: OHS Mechanisms CPAP vs BiPAP OHS-

  11. Differences: normal, obesity and hypoventilation Key aspect: OHS Volume Failure: Pathways CPAP vs BiPAP OHS-

  12. PathwaysdaytimehypercapniaChronicHypercapnia

  13. Key aspect: OHS Lung-effects CPAP vs BiPAP OHS-

  14. HypoxemiaduringCPAP therapy

  15. Key aspect: Obesity-OHS Hypoxemiaduring CPAP therapy CPAP vs BiPAP OHS-

  16. SummaryOHS-CPAP-vs BiPAP

  17. Key aspect: SummaryStudies OHS Prevalence-1 CPAP vs BiPAP OHS-

  18. Key aspect: OHS Arterial Blood Gases Response-2 CPAP vs BiPAP OHS-

  19. 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

  20. NPPV-Short-term and long term positive airway pressure therapy on Pulmonary Function Key aspect: OHS PulmonaryFunction-4 CPAP vs BiPAP OHS-

  21. 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-

  22. Summary Results -1 CPAP vs BiPAP OHS-1

  23. Summary Results -2 CPAP vs BiPAP OHS-2

  24. Summary Results -3 CPAP vs BiPAP OHS-3

  25. OHSShort and Long TermEffects

  26. Key aspect: OHS Short and Long Term Effects-2 CPAP vs BiPAP OHS-

  27. Key aspect: OHS Survival Months (18 months) CPAP vs BiPAP OHS- Months after diagnosis of OHS

  28. Risk of MortalityOHSCPAP-vs BiPAP

  29. Factors influencing long-term survival in OHS Key aspect: Obesity-OHS Long-termOutcome OHS-5 (6 months) Relativerisk of death CPAP vs BiPAP OHS-

  30. Methodology and Practice OHSCPAP and PAP

  31. Initialtherapy, Acute, chronicSituationsPh/pCO2 trends

  32. Key aspect: OHS Initialtherapy, Acute, chronic Situations Ph/pCO2 trends CPAP vs BiPAP OHS-

  33. Noninvasive Ventilation

  34. 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

  35. BackupRespiratoryRatefactor

  36. Key aspect: BackupRespiratoryRatefactor CPAP vs BiPAP OHS-

  37. 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

  38. OHS ResponseHypercapnic FailureafterPAP therapy

  39. 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-

  40. Complianceand non compliance

  41. Key aspect: OHS Interface CPAP vs BiPAP OHS-

  42. Acute Hypercapnic Respiratory Failure Interface- clinical-technical factors

  43. Key aspect: OHS Compliance And non compliance CPAP vs BiPAP OHS-

  44. Summary and conclusions forpracticaldecisions OHS CPAP versus BIPAP

  45. 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

  46. 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

  47. 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

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