Cases reported "Obesity"

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1/8. Restructuring the therapeutic environment to promote care and safety for the obese patient.

    Fifty-four percent of American adults are overweight. obesity is a chronic disease associated with a number of conditions, such as diabetes, heart disease, hypertension, certain types of cancers, and breathing problems. The direct and indirect costs related to obesity exceed $70 billion annually. Because of the many cost and quality issues related to obesity, national attention is turning toward the special needs of this population. Strategies to restructure therapeutic intervention with attention to risk management, economic implications, and patient satisfaction are important considerations when managing the obese patient.
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2/8. Primary pulmonary hypertension with central sleep apnea: sudden death after bilevel positive airway pressure therapy.

    An obese 23-year-old man with sleep-disordered breathing and primary pulmonary hypertension (PPH) had been administered oral beraprost sodium, anticoagulant warfarin, and home oxygen therapy, at another hospital as treatment for the PPH, but he had not experienced any symptomatic improvement. The patient had a body mass index of 32.4kg/m2, and complained of fatigue, shortness of breath on exertion, excessive daytime sleepiness, and snoring. Arterial blood gas analysis showed a PaO2 and a PaCO2 of 70.9 and 31.2mmHg, respectively. A polysomnographic study revealed central sleep apnea with an apnea-hypopnea index (AHI) of 29.7episodes/h. The patient showed improvement of daytime sleepiness after starting nocturnal nasal bilevel positive airway pressure (BiPAP) therapy for the central sleep apnea, but his pulmonary hypertension, measured in the daytime, worsened. The patient died suddenly while walking to the bathroom in the morning 1 month after initiation of BiPAP therapy. It is necessary to consider the possibility of sudden death when nasal BiPAP therapy is given to a PPH patient with central sleep apnea.
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3/8. Pickwickian syndrome, 20 years later.

    The Pickwickian syndrome stimulated new pathophysiological concepts in regard to control of ventilation. With the advent of sleep laboratories, the peculiar sleep apnea occurring in some of these patients has been explained on the basis of intermittent upper airway obstruction. Two patients with different manifestations of the Pickwickian syndrome are presented. The suggestion is made that these two subsyndromes should have unique designations. The Auchincloss syndrome is manifested by right heart failure and respiratory acidosis in obese patients who are alert and have no major abnormality of breathing pattern. The fundamental cause of this abnormality is the increased work of breathing caused by the obesity. The cost of breathing is so high that the ventilatory regulation is compromised and respiratory acidosis results. The Gastaut syndrome is characterized principally by hypersomnia and sleep apnea. The fundamental defect is upper airway obstruction during sleep, resulting in increased work of breathing, which together with the increased work caused by obesity leads to respiratory acidosis and right ventricular failure. Hypersomnia, rather than heart failure or respiratory acidosis, is the major manifestation of this syndrome, and is the result of sleep loss.
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4/8. obesity as a possible cause of respiratory failure in bilateral diaphragmatic paralysis. Case report.

    An obese woman with respiratory failure and bilateral diaphragmatic paralysis, was studied in order to investigate the effects of weight loss on respiratory function during wakefulness and sleep. The patient was studied on 5 different occasions during which diurnal blood gas analysis, spirometry, CO2 rebreathing test, nitrogen wash-out test and a nocturnal polysomnographic study were performed. The follow-up period lasted 9 months, during which the patient progressively lost 19 kg. Progressive improvement in awake blood gas tensions (PaO2 21 mmHg, PaCO2 - 16 mmHg) as well as in nocturnal oxyhemoglobin saturation and transcutaneous PCO2 were observed; at the same time only minor changes in responsiveness to CO2 and in lung volumes were found. Conversely alveolar efficiency for CO2, obtained with the nitrogen wash-out test, in the supine posture increased from 81.7 to 90.5%, indicating an improvement in ventilation/perfusion ratio as a possible determinant of blood gas tension improvement during wakefulness and, as a consequence, also during sleep. We conclude that obesity is one possible cause of the occurrence of respiratory failure in bilateral diaphragmatic paralysis.
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5/8. Cure of sleep apnea syndrome after long-term nasal continuous positive airway pressure therapy and weight loss.

    Two male patients [aged 53 and 54 years; body mass index (BMI) of 36.8 and 34.4 kg/m2] presented with severely symptomatic sleep apnea syndrome. Polysomnographic recording showed sleep fragmentation, diminution of stages III and IV and continuous sleep-related disordered breathing with mixed and obstructive apneas and hypopneas, and snoring. apnea index (number of apneas per sleep-hour) was 73 and 30, respectively. These abnormalities were reversed by nasal continuous positive airway pressure (nCPAP). Home treatment with nCPAP associated with hypocaloric diet was started. Six months later, all symptoms had disappeared and BMI was 29 and 29.2 kg/m2, respectively. Polygraphic recordings without nCPAP showed regular breathing in all sleep stages, which were stable and normally abundant. Therapy has been discontinued and clinical and polygraphic data have remained normal for up to 6 and 11 months, respectively.
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6/8. Chronic respiratory failure and physical reconditioning: case study of an elderly obese woman.

    A case is described of a 67 year old obese white woman who had a history of multiple medical problems and who was in chronic respiratory failure but responded poorly to intermittent positive pressure breathing, chest physiotherapy, and supplementary oxygen. She was treated successfully with a 600 k.cal diet and a 26-day physical reconditioning programme. Reconditioning techniques included free and treadmill walking, stair climbing, bench stepping, light calisthenics, and breathing retraining. Improvements were noticed in blood gases, spirometry, electrocardiogram, motor coordination, and physical working capacity.
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7/8. Multifactorial obstructive sleep apnea in a patient with Chiari malformation.

    We report a patient with severe obstructive sleep apnea (OSA) associated with a unique combination of syringobulbia-myelia, Chiari malformation type I (CM), absent hypoxic ventilatory drive, vocal cord paralysis, post-menopausal status, obesity, and acute respiratory failure necessitating mechanical ventilation. The remote onset of OSA five years after surgery underscores the need for long-term follow-up of patients with syringobulbia-myelia and CM and the importance of addressing multiple interacting neurologic, metabolic, and mechanical predispositions to sleep-disordered breathing.
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8/8. Obstructive sleep apnea manifesting as suspected angina: report of three cases.

    OBJECTIVE: To describe three cases of obstructive sleep apnea that resembled coronary artery disease and to suggest features that might distinguish these two syndromes. DESIGN: We present three detailed case reports of patients with severe obstructive sleep apnea and discuss similar cases from the literature. MATERIAL AND methods: Two obese women and one obese man with previously undiagnosed obstructive sleep apnea had chest discomfort, episodic dyspnea, and palpitations, most prominent at night. All three patients had multiple cardiac risk factors and had previously undergone cardiac evaluations, including at least two prior cardiac catheterizations each. Repeated cardiac catheterization revealed less coronary occlusive disease than expected on the basis of the symptoms in all three patients and a small atrial septal defect in one patient. When reassessed, the medical histories suggested obstructive sleep apnea. RESULTS: Overnight polysomnography documented the presence of severe sleep apnea; the three patients had mean values of 56 disordered breathing events per hour and 44% minimal oxygen saturation. Although bi-level or continuous positive airway pressure yielded initial improvement, all patients had difficulty with routine use of this therapy after 1 1/2 years of follow-up. CONCLUSION: The initial manifestations of severe obstructive sleep apnea may simulate angina, suggest arrhythmia, or mimic heart failure. Failure to inquire about snoring and daytime somnolence in patients with chest pain may prevent the identification of clinically significant disordered breathing during sleep.
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