Obesity and Respiration 2016

Obesity and Respiration - Dr. Parthiv Mehta

Obesity and

RESPIRATION

Dr. Parthiv MEHTA

Central UNITED Hospital

Ahmedabad

GOAL

• Increase awareness towards Obesity

• Understand Obesity relatedRespiratory Disorder - Sleep Apnoea –with reference to risks if untreated

• Educate / Revise recognizing,preventing and treating Sleep Apnoea

• Definition….

Obesity

Obesity

100 ______________1.80 X 1.80

= 30.7

• BMI over 25….. Kg/m2

• BMI Calculator…

Weight in kg_____________________________Height in meter X Height in meter

www.bmi3d.com

• Scientists have identified SNP (single nucleotidepolymorphism) named “rs12970134” to be mostlyassociated with waist circumference.

• Over 2000 individuals of Indian origin participatedand SNP “rs12970134” is found highly prevalent.

• Internationally, a BMI over 25 kg/m2 is consideredoverweight. Due to genetic tendency of Indianstowards abdominal obesity and its associated riskof related lifestyle diseases like Diabetes & HeartDisease,

Ministry of Health & Family Welfare and ICMR released updated guidelines (in 2012) that

BMI over 23 kg/m2 is considered overweight.

Normal : 18.0-22.9 kg/m2

Overweight: 23.0-24.9 kg/m2

Obesity: >25 kg/m2

Obesity - INDIA

Obesity - INDIA

• Obesity has reached epidemicproportions in India, with morbidobesity affecting 5% of the country'spopulation.

Male Female

India Gujarat India Gujarat

12.1 15.4 16.0 17.7

Obesity - INDIA

Obesity

Human Lung…

• 22-24 generations

• >1,00,000 bronchi,

bronchioles

• 2400 km of airways

• 30-50 Cr alveoli

• 0.3mm in diameter

• Surface area 70m2

• Capillaries 992 km end to end

Human Lung…

Human Lung…

Human Lung…

Respiration: Air - In and Out of Lungs

I’m Thin, My Lungs are Happy..

I’m Moderate…Lungs feel OK..

Oh dear…I’m Compressed..


See the Difference…

Our Nose & Throat…





With Obesity…

FAT

079 26854849

079 26854849

079 26854849

While asleep…


FLOW

TIME

Open Airway


Flow Limitation

TIME

FLOW

While asleep…SNORING…


SnoreFLO

W

TIME

Severe Cases….AWAKENING..


Apnea

TIME

FLOW

Sleep Apnoea - Mechanism

• During sleep

– When the muscles at the back of theairway relax and the upper airwaypartially or completely collapses

– Leads to obstruction in breathing andrestricts airflow.

• Snoring is a common symptom of SA.

Every Snorer may not be Apnoeic

Sleep Apnoea - Mechanism

Sleep Apnoea

• Sleep Apnoea (SA) is disordered breathingduring sleep.

• The airway is mechanically obstructedcausing a cessation of breathing - OSA.

• An apnoea occurs when a person stopsbreathing for 10 seconds or more.

• If untreated can lead to Cardiovascularand Cerebro-vascular disease and Injuryfrom vehicular accidents because ofsleepiness.

Sleep Apnoea

Symptoms Snoring Night time gasping or pauses in breathing Morning headaches Daytime fatigue Excessive drowsiness at Day Body ache – Leg cramps Difficulty in concentration Forgetfulness Overweight & obesity High Blood Pressure

Towards the End of Day

Sleep Apnoea – Reasons…

Mechanical obstruction of the airway

BMI (body mass index) of 25 or above -Obesity

Short neck or Excessive tissue in neck area

Aging process which causes the neckmuscles to loose tone and collapse whenlying supine

Crowded teeth and narrow palate inchildren

Sleep Apnoea – Existence..


OSA – “Pickwickian Syndromme”: 1836

• Joe – “The Fat Boy”

who was described by

Charles Dickens in

“The Pickwick Papers”

had typical features

with snoring, obesity

and sleepiness.

W. H. Broadbent: Lancet (1877)• “When a person, especially advanced in years, is lying

on his back in heavy sleep and snoring loudly,

• it very commonly happens that every now and theninspiration fails to overcome the resistance in thepharynx - of which stridor or snoring is the audible sign,

• and there will be perfect silence through two, three, orfour respiratory periods, in which there are ineffectualchest movements;

• finally, air enters with a loud snort, after which thereare several compensatory deep inspirations before thebreathing settles down to its usual rhythm..”


Why Don’t Animal Get it??



Sleep Apnoea - Burden

• 42 million Americans suffer from OSA

– Found across all age groups, both sexes,all socioeconomic classes and ethnicgroups

– Most common in obese middle-aged menand obese postmenopausal women

• 4-9% of Population in INDIA fall in HighRisk group

Young et al. Sleep 2008

Sleep Apnoea – Effect on Body

During an apnoea At the end of an apnoea

Oxygen levels begin todecrease

Oxygen “recovers” uponarousal (though this maytake several minutes)

Heart rate slows Dramatic rise in heart rate

Blood pressure dropsDramatic rise in bloodpressure

Sleep Apnoea –A Common Companion

Diabetes

Obesity

All Hypertension

Atrial Fibrillation

Congestive Heart Failure

Drug-ResistantHypertension

Coronary Artery Disease

Pacemakers

80%

50%

35%

50%

Sjostrom et al,Thorax, 2002

Logan et al,J. Hypertension, 2001

Javaheri et al,Circulation, 1999

O'Keeffe & Patterson, Obes Surgery, 2004

Einhorn et al.Endocrine Prac, 2007

50% Somers et al,Circulation, 2004

77%

30%

59%Garrigue et al.Circulation 2007

Schafer et al.Cardiology 1999

Sleep Apnoea –A Common Companion

Diabetes

Obesity

All Hypertension

Atrial Fibrillation

Congestive Heart Failure

Drug-ResistantHypertension

Coronary Artery Disease

Pacemakers

80%

50%

35%

50%

Sjostrom et al,Thorax, 2002

Logan et al,J. Hypertension, 2001

Javaheri et al,Circulation, 1999

O'Keeffe & Patterson, Obes Surgery, 2004

Einhorn et al.Endocrine Prac, 2007

50% Somers et al,Circulation, 2004

77%

30%

59%Garrigue et al.Circulation 2007

Schafer et al.Cardiology 1999

Sleep Apnoea – Impact on Heart

Postgrad Med J 2008; 84:15-22


High Blood Pressure – All cause Hypertension

• 3 times higher risk to develop High Bloodpressure

• ~40% of people with OSA have high bloodpressure while awake

Heart Attack – Ischaemia / Infarction

• 36% of patients with OSA had Fatal or Non fatalevent.

• Sudden death from cardiac causes (betweenmidnight and 6 am) occurred in 46% of pts withOSA v/s 16% of general population

Sleep Apnea is an identifiable cause of hypertension according to the National Institute of Health (NIH)


Heart Failure - CCF• 3 times more common in “mild-moderate OSA”

then in “no OSA”Abnormal Heart Beats – Arrhythmia• 48% had cardiac arrhythmias at night - 2%

sustained VT, 11% sinus arrest, 8% AV block, 19%VPC

• 4 times increased risk of AF in pts with OSA(AHI>30) (Sleep Heart Health Study 2006)

• Onset of >75% of persistent AF episodes in pts withOSA occur at night (8pm-8am)

• AF recurrence after cardio-version twice as high inuntreated OSA

Sleep Apnoea – Impact of Treatment

High Blood Pressure:

• Proven benefits from sleep apnoea therapy inlowering blood pressure

– 4mm Hg to 10mm Hg reduction with CPAP therapy

• Study showed a fall in systolic BP by 10 mmafter 4 weeks of CPAP

• Improvement in blood pressure correlatedwith improvement / reduction in sleepiness.

Becker et al. Circulation 2003

Sleep Apnoea – Impact of Treatment

Cardiac Failure:

• Proven benefits from sleep apnoea therapy inimproving cardiovascular health

– Left ventricular ejection fraction, six-minute walk, VO2 max, after load, BNPKaneko et al. NEJM 2003, Maisel et al. UCSD VA Hospital – Case Study Data (2002), Teschler et al. AJRCCM 2001

• 8 patients with dilated DCM and OSA: one month-increased EF 37% to 49%, improved dyspnea:improvement reversed one week after withdrawal

• 24 patients with HF and OSA: randomized: 1 month:mean decrease in day time HR, BP, increased EF by 9%

Postgrad Med J 2008; 84:15-22Proc Am Thorac Soc 2008; 5:200-206

Sleep Apnoea – IMPACT of AWARENESS

• Widespread public awareness resulted intoan 80% increase of newly diagnosed cases ofOSA over the next 24 months

• With the initiation of early therapy,morbidity and mortality rates due to relatedcardiovascular disease in the at riskpopulation reduced by 60% within the next48 months.

healthypeople.org. Healthy People 2010. Retrieved November 17, 2003, ProQuest

Let us Recap…..Obesity

SLEEP, Vol. 30, No. 3, 2007

Sleep Apnoea – Wagon Wheel

High Blood

Pressure

Cardiac Problems:

CCF, Arrhythmia, Heart Attack

Memory Problems:

Inability to think correctly

Insulin Resistance:

Even in non-Diabetic

IncreasedAccidents:

Road Traffic Work place

Stroke

Obstructive Sleep

Apnoea

Take Home Message…

• There is a clear association betweenObesity, OSA and cardiovascular disease

• Higher incidence of adversecardiovascular events in untreatedpatients with Obesity and OSA

• Early Detection and Treatment helps toeliminate potential Cardio-Vascular Risksand reduces morbidity and mortality.

Postgrad Med J 2008; 84:15-22 SLEEP 2007;30(3):291-304CHEST 2008; 133:793-804 Proc Am Thorac Soc 2008; 5:200-206

If UNTREATED…..

Take Home Message…Obesity with Sleep Apnoea can

SINK LIFE..

Further references…

Health & Medicine

Obesity and Respiration 2016