Morbid obesity with respiratory manifestations

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He presents hypertension (200/100 mmHg), tachycardia. (96 bpm), tachypnea (22 ... percapnia (pH α 7,43; PaO2 α 50 mm Hg; PaCO2 α 58 mm Hg). Questions:.
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„‡œ‹–ƒ–‡ƒ‘”„‹†£…— ƒ‹ˆ‡•–£”‹”‡•’‹”ƒ–‘”‹‹

Morbid obesity with respiratory manifestations

Victor Botnaru1ǡŽ‡šƒ†”—‘”Ž£–‡ƒ—1ǡ‹…–‘”‹ƒÁ”…—1*, Eugenia Scutaru1ǡ‡”‰Š‡‹‘˜ƒì‡˜1

Victor Botnaru1, Alexandru Corlateanu1, Victoria Sircu1*, Eugenia Scutaru1, Serghei Covantev1

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1 ‹˜‹•‹on oˆ ’n‡—oŽo‰› ƒn† ƒŽŽ‡”‰oŽo‰›ǡ ‡’ƒ”–‡n– oˆ ‹n–‡”nƒŽ ‡†‹c‹n‡ǡ ‹coŽƒ‡ ‡•–‡‹ìƒn— S–ƒ–‡ n‹˜‡”•‹–› oˆ ‡†‹c‹n‡ ƒn† PŠƒ”ƒc›ǡ Š‹•‹nƒ—ǡ ‡’—„Ž‹c oˆ oŽ†o˜ƒǤ

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Autor corespondent: ”Ǥ ‹c–o”‹ƒ SÁ”c— ‹•c‹’Ž‹nƒ †‡ ’n‡—oŽo‰‹‡ ç‹ ƒŽ‡”‰oŽo‰‹‡ ‡’ƒ”–ƒ‡n–—Ž †‡ ‡†‹c‹n£ ‹n–‡”n£ n‹˜‡”•‹–ƒ–‡ƒ †‡ S–ƒ– †‡ ‡†‹c‹n£ ç‹ ƒ”ƒc‹‡ Ƿ‹coŽƒ‡ ‡•–‡‹ìƒn—dz „†Ǥ f–‡ˆƒn c‡Ž ƒ”‡ ç‹ SˆŸn–ǡ 1ͼͻǡ Š‹ç‹n£—ǡ ‡’—„Ž‹cƒ oŽ†o˜ƒǡ Ǧ͸ͶͶͺ ‡Ǧƒ‹Ž: •‹”c—Ǥ˜‹c–o”‹ƒ̻›ƒŠooǤco

Corresponding author: ”Ǥ ‹c–o”‹ƒ S‹”c— ‹˜‹•‹on oˆ ’n‡—oŽo‰› ƒn† ƒŽŽ‡”‰oŽo‰› ‡’ƒ”–‡n– oˆ In–‡”nƒŽ ‡†‹c‹n‡ ‹coŽƒ‡‡•–‡‹–ƒn— S–ƒ–‡ n‹˜‡”•‹–› oˆ ‡†‹c‹n‡ ƒn† PŠƒ”ƒc› 1ͼͻǡ S–‡ˆƒn c‡Ž ƒ”‡ •‹ Sˆƒn– ƒ˜‡Ǥǡ Š‹•‹nƒ—ǡ ‡’—„Ž‹c oˆ oŽ†o˜ƒǡ Ǧ͸ͶͶͺ ‡Ǧƒ‹Ž: •‹”c—Ǥ˜‹c–o”‹ƒ̻›ƒŠooǤco

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Male patient, age 44, university professor, non-smoker, presents pronounced dyspnea on exertion, at minimal effort, orthopnea, choking during sleep, loud snoring during sleep, breathing pauses during sleep reported by his wife, insomnias during night, nocturia 4-5 times/night, nocturnal xerostomia, nocturnal sweating, morning headache, fatigue, daytime sleepiness and high blood pressure. Patient mentions snoring for approximately 20 years, during this period he added over 170 kg of weight, the last 8 years he sleeps in half-seated position, hypertension for 16 years, –›’‡ʹ†‹ƒ„‡–‡•‡ŽŽ‹–—•ˆ‘”ͺ›‡ƒ”•ǡ–”‡ƒ–‡†™‹–Š‡–ˆ‘”‹ǣ glycated hemoglobin 7,5%. Physical examination revealed male with morbid obesity ȋ™‡‹‰Š–αʹ͸ͷ‰ǡŠ‡‹‰Š–αͳͺʹ…ǡ αͺͲ‰Ȁ2, neck cir…—ˆ‡”‡…‡ α ͸Ͳ …ǡ ƒ„†‘‹ƒŽ …‹”…—ˆ‡”‡…‡ α ͳͻͲ …Ȍǡ pale skin, pronounced bilateral peripheral edema, trophic changes with the presence of ulcers bilaterally on legs (Figure 1). He presents hypertension (200/100 mmHg), tachycardia (96 bpm), tachypnea (22 bpm), SaO2 70% (without oxygen support). —”‹‰ ƒ—•…—Ž–ƒ–‹‘ Ȃ ”‡†—…‡† ˜‡•‹…—Žƒ” „”‡ƒ–Š •‘—†•ǡ rhythmic and attenuated heart sound. Abdomen increased in volume from the adipose tissue, no pain during palpation. The Mallampati score was IV and Epworth Sleepiness Scale was 16 points. Chest X-ray was normal, ECG revealed signs of right ventricular strain. The EchoCG revealed moderate dilation of both atria, reduced ejection fraction (41%), severe right ventricle (RV) dilatation and moderate pulmonary hypertension (pulmonary artery systolic pressure 49 mm Hg). Spirometry at-

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MJHS 17(3)/2018

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Tiffeneau 79%, iar gazimetria sângelui arterial pune în evi†‡ì£‘Š‹’‘š‡‹‡…—Š‹’‡”…ƒ’‹‡—葃”£ȋ’ α͹ǡͶ͵ǡƒ2αͷͲ mmHg, PaCO2αͷͺ ‰ȌǤ

–‡•–• ͳ Ȃ ͸ʹΨǢ  Ȃ ͷͲΨǢ ‹ˆˆ‡‡ƒ— ‹†‡š Ȃ ͹ͻΨǡ ƒ† arterial blood gases values highlights hypoxemia and mild hy’‡”…ƒ’‹ƒȋ’ α͹ǡͶ͵Ǣƒ2αͷͲ ‰Ǣƒ2αͷͺ ‰ȌǤ

B–”‡„£”‹ǣ ͳȌ‘•‹†‡”Ÿ††ƒ–‡Ž‡ƒƒ‡•–‹…‡ç‹‡šƒ‡—Ž…Ž‹‹…ǡ…ƒ”‡ ‡•–‡†‹ƒ‰‘•–‹…—Žƒ‹’”‘„ƒ„‹Žǫ ʹȌƒ”‡•—–…”‹–‡”‹‹Ž‡†‡†‹ƒ‰‘•–‹…ǫ—‹ì‹‘Ž‹•–£†‡†‹ƒ‰‘•–‹…†‹ˆ‡”‡ì‹ƒŽǤ ͵Ȍƒ”‡‡•–‡–”ƒ–ƒ‡–—Žƒ…‡•–‡‹ƒŽƒ†‹‹ǫ

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Fig. 2 B”‡‰‹•–”ƒ”‡’‘Ž‹‰”ƒϐ‹…£Ȃ–”ƒ•‡—͵Ͳ‹Ǥ‡–”ƒ•‡—Ž’‘Ž‹‰”ƒϐ‹‡‹”‡•piratorii au fost înregistrate mai multe apnei cu durata peste 10 secunde, Á•‘ì‹–‡†‡‡ˆ‘”–”‡•’‹”ƒ–‘”’”‡œ‡–ǡ…‘–‹——’‡Á–”‡ƒ‰ƒ’‡”‹‘ƒ†£†‡ ƒ„•‡ì£ƒϐŽ—š—Ž—‹ƒ‡”‹ƒè‹ƒ•‘…‹ƒ–‡…—†‡•ƒ–—”£”‹•‡‹ϐ‹…ƒ–‹˜‡Ǥ Fig. 2 PoŽ›‰”ƒ’Š‹c ”‡‰‹•–‡”‹n‰ Ȃ ͹Ͷ ‹n –”ƒ‹ŽǤ n –Š‡ ”‡•’‹”ƒ–o”› ’oŽ›‰”ƒ’Š‹c –”ƒ‹Ž –Š‡”‡ ™‡”‡ ”‡‰‹•–‡”‡† o”‡ ƒ’n‡ƒǡ o˜‡” 1Ͷ •‡con†•ǡ ƒcco’ƒn‹‡† „› –Š‡ ’”‡•‡nc‡ oˆ ”‡•’‹”ƒ–o”› ‡ˆˆo”–ǡ con–‹n—o—• †—”‹n‰ –Š‡ ™ŠoŽ‡ ’‡”‹o† oˆ ƒ‹”ϔŽo™ ƒ„•‡nc‡ǡ ƒ••oc‹ƒ–‡† ™‹–Š •‹‰n‹ϔ‹cƒn– †‡•ƒ–—”ƒ–‹on•Ǥ Fig. 1 ƒ…‹‡–—ŽǤ‡‘–ƒ–‘„‡œ‹–ƒ–‡ƒ‘”„‹†£ç‹‰Ÿ–—Ž•…—”–ǡ ’‡‡„”‡Ž‡‹ˆ‡”‹‘ƒ”‡Ȃ•…Š‹„£”‹–”‘ϐ‹…‡Ǥ Fig. 1 Š‡ ’ƒ–‹‡n–Ǥ o „‡ no–‡† o”„‹† o„‡•‹–›ǡ •Šo”– n‡cǡ –”o’Š‹c cŠƒn‰‡• on Žo™‡” Ž‹„•Ǥ

‹‰Ǥ͵Evaluarea terapiei cu BiPAP 17/11 cm H2O la 3 luni (evaluarea …‘’Ž‹ƒì‡‹’ƒ…‹‡–—Ž—‹ȌǤ Fig. 3 B‹PP 1ͽȀ11 c ͸ –Š‡”ƒ’› ‡˜ƒŽ—ƒ–‹on ƒˆ–‡” ͹ on–Š• ȋƒ••‡••‹n‰ ’ƒ–‹‡n– co’Ž‹ƒnc‡ȌǤ

‹‰ǤͶƒ…‹‡–—Ž†—’£—ƒ†‡–”ƒ–ƒ‡–Ǥ‡‘–ƒ–•…£†‡”‡ƒ masei corporale. Fig. 4 Pƒ–‹‡n– ƒˆ–‡” on‡ ›‡ƒ” oˆ –”‡ƒ–‡n–Ǥ o „‡ no–‡† „o†› ™‡‹‰Š– Žo••Ǥ

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£•’—•ǣ ͳȌ ‹ƒ‰‘•–‹…—Ž †‹ˆ‡”‡ì‹ƒŽ –”‡„—‹‡ •£ ‹…Ž—†£ǣ ȋͳȌ •‹†”‘mul de apnee în somn de tip obstructiv (SASO); (2) sindromul †‡ ‘„‡œ‹–ƒ–‡ Š‹’‘˜‡–‹Žƒì‹‡ ȋ ȌǢ ȋ͵Ȍ ‹•—ϐ‹…‹‡ìƒ …ƒ”†‹ƒ…£ †”‡ƒ’–£Ǥ ƒ…‹‡ì‹‹…—•…£†‡”‡ƒ…ƒŽ‹–£ì‹‹•‘—Ž—‹ǡ•ˆ‘”£‹–ǡƒ•–‡‹‡Á –‹’—Žœ‹Ž‡‹è‹’”‡œ‡ìƒƒ’‡‡Ž‘”Á–‹’—Ž•‘—Ž—‹ȋ‘„•‡”˜ƒ–‡†‡’ƒ”–‡‡”Ȍǡ•—‰‡”‡ƒœ£†‹ƒ‰‘•–‹…—Ž†‡Ǥ—Ž†‹–”‡ …‡‹ƒ‹‹’‘”–ƒì‹ˆƒ…–‘”‹†‡”‹•…’‡–”—‡•–‡…”‡è–‡”‡ƒ ’‘†‡”ƒŽ£Ǥ‡”‡‰—Ž£ǡ’ƒ…‹‡ì‹‹’”‡œ‹–£…‘‘”„‹†‹–£ì‹…ƒ”†‹‘˜ƒ•…—Žƒ”‡è‹‡–ƒ„‘Ž‹…‡ƒ•‘…‹ƒ–‡Ǥ   ‡•–‡ ‘ ƒˆ‡…ì‹—‡ǡ Á …ƒ”‡ — ’ƒ…‹‡– •—’”ƒ’‘†‡”ƒŽ — ”‡—è‡è–‡ •£ ”‡•’‹”‡ Á ‘† ƒ†‡…˜ƒ– Á –‹’—Ž •‘—Ž—‹ǡ …ƒ—œŸ† Š‹’‘š‹‡ è‹ Š‹’‡”…ƒ’‹‡Ǥ ‡è‹   ’‘ƒ–‡ ϐ‹ ‘ ‡–‹–ƒ–‡ •‡’ƒ”ƒ–£ǡ ’ƒ…‹‡ì‹‹ǡ ˆ”‡…˜‡–ǡ ƒ— ‡’‹•‘ƒ†‡ †‡ ƒ’‡‡ǡ ƒ•–ˆ‡Ž …£ǡ adeseori, SOH se suprapune cu SASO. Simptomele sunt simiŽƒ”‡ …— …‡Ž‡ †‹ ǡ ‹ƒ” †‹ˆ‡”‡ìƒ ‡•–‡ ‘„•‡”˜ƒ–£ Á –‹’—Ž ’‘Ž‹•‘‘‰”ƒϐ‹‡‹ •ƒ— ’‘Ž‹‰”ƒϐ‹‡‹ …ƒ”†‹‘”‡•’‹”ƒ–‘”‹‹Ǥ   ‡•–‡ — †‹ƒ‰‘•–‹… †‡ ‡š…Ž—†‡”‡ǡ ’”‹ —”ƒ”‡ǡ –”‡„—‹‡ ‡˜ƒŽ—ƒ–‡ è‹ ƒŽ–‡…‘†‹ì‹‹…‡’‘–†‡–‡”‹ƒŠ‹’‘˜‡–‹Žƒì‹ƒǤ ʹȌ ‡•–‡†‡ϐ‹‹–’”‹ƒ•‘…‹‡”‡ƒ‘„‡œ‹–£ì‹‹ȋ η͵Ͳ‰Ȁ m2Ȍ…—Š‹’‘˜‡–‹Žƒì‹ƒƒŽ˜‡‘Žƒ”£ǡÁ•‘ì‹–£†‡Š‹’‡”…ƒ’‹‡Á–‹pul zilei (PaCO2ηͶͷ ‰ǡƒ2δ͹Ͳ ‰ȌǤ‡•–‡†‡ϐ‹‹–’”‹’”‡œ‡ìƒ—£”—Ž—‹†‡‡˜‡‹‡–‡”‡’‹”ƒ–‘”‹‹ȋƒ’‡‹ǡ Š‹’‘’‡‹Ȍηͷ’‡‘”£ȋ‹†‹…‡Ž‡†‡ƒ’‡‡ȀŠ‹’‘’‡‡Ȃ  ȌǤ •‡ƒ•‘…‹ƒœ£…— Áƒ’”‘š‹ƒ–‹˜ͻͲΨ†‹…ƒœ—”‹Ǥ‹•–ƒ†‡†‹ƒ‰‘•–‹…†‹ˆ‡”‡ì‹ƒŽƒŽ ’‘ƒ–‡‹…Ž—†‡ǣƒˆ‡…ì‹—‹Ž‡‘„•–”—…–‹˜‡•‡˜‡”‡ǡ„‘Ž‹Ž‡’—Ž‘ƒ”‡‹–‡”•–‹ì‹ƒŽ‡ƒ˜ƒ•ƒ–‡ǡ†‡ˆ‘”ƒì‹‹ •‡˜‡”‡ƒŽ‡’‡”‡–‡Ž—‹–‘”ƒ…‹…ȋ†‡‡š‡’Ž—ǡ…‹ˆ‘•…‘Ž‹‘œ£ȌǡŠ‹’‘–‹roidismul sever, boli neuromusculare, sindromul de hipoven–‹Žƒì‹‡…‘‰‡‹–ƒŽ£ȋ”ƒ”‹•‹ȌǤ ͵Ȍ”ƒ–ƒ‡–—Ž ‹…Ž—†‡˜‡–‹Žƒì‹ƒ‡‹˜ƒœ‹˜£ǡ…Š‹”—”‰‹ƒ „ƒ”‹ƒ–”‹…£è‹ƒƒ‰‡‡–—Ž…‘‘”„‹†‹–£ì‹Ž‘”Ǥ‡”ƒ’‹ƒ…— ’‘ƒ–‡ϐ‹‹‹ì‹ƒ–£’‡–”—ƒ‡Ž‹‹ƒ‡˜‡‹‡–‡Ž‡‘„•–”—…–‹˜‡è‹ Ž‹‹–£”‹Ž‡ϐŽ—š—Ž—‹Ǥƒ…£ƒ2•‡‡ì‹‡•—„ͻͲΨ’‡–”—ƒ‹ mult de 20% din durata somnului, pe fundal de CPAP, sau pacientul este intolerant la o presiune mai mare pe CPAP (14 cm H2Ȍǡ ‡…‡•ƒ”£ ’‡–”— ƒ ÁŽ£–—”ƒ ƒ’‡‡Ž‡ȀŠ‹’‘’‡‡Ž‡ǡ ƒ–—…‹ •‡ —–‹Ž‹œ‡ƒœ£ ‹Ǧ—ŽǤ ‹ˆ‡”‡ìƒ †‹–”‡  è‹  –”‡„—‹‡ •£ ϐ‹‡ǡ †‡ …‡Ž ’—싐ǡ ͺǦͳͲ … 2Ǥ ƒ…£ •ƒ–—”ƒì‹ƒ •‡ ‡ì‹‡ •—„ͻͲΨǡ‡•–‡‡…‡•ƒ”£ƒ•‘…‹‡”‡ƒ‘š‹‰‡‘–‡”ƒ’‹‡‹Ǥ—’£…‡’ƒcientul este stabilizat, acesta va necesita un tratament supli‡–ƒ”ǡ’‡–”—…‘”‹Œƒ”‡ƒ‰”‡—–£ì‹‹…‘”’—Ž—‹è‹…‘‘”„‹†‹–£ì‹Ž‘”Ǥ Comentarii Pacientul a fost diagnosticat cu SOH conform rezultatelor ’‘Ž‹‰”ƒϐ‹‡‹ …ƒ”†‹‘”‡•’‹”ƒ–‘”‹‹ è‹ Ǣ ƒ…‡ƒ•–ƒ ‡•–‡ ‘ …‘†‹ì‹‡ǡ ƒ†‡•‡‘”‹ǡ‰”‡è‹–†‹ƒ‰‘•–‹…ƒ–£Ǥ ’”‡œ‹–£•‡‡è‹•‹’–‘me complexe, cu IMC