Scientific Letter
Prognosis of Obesity Hypoventilation Syndrome With and Without Concomitant Obstructive Sleep Apnea Syndrome
Pronóstico del síndrome de hipoventilación-obesidad con y sin síndrome de apnea obstructiva asociado
Ana Rodriguez Alvarez, Lidia Méndez Marote, Olalla Castro Añón, Rafael Golpe Gómez, Luis Alejandro Pérez de Llano
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Servicio de Neumología, Hospital Universitario Lucus Augusti, Lugo, Spain
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However, the lack of a universally accepted definition creates confusion, since no distinctions are made between patients with different grades of severity and forms associated, or not associated, with sleep apnea-hypopnea syndrome (SAHS).<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">1–3</span></a> Cabrera et al. proposed a severity stratification for OHS based on daytime PaO<span class="elsevierStyleInf">2</span>, PaCO<span class="elsevierStyleInf">2</span>, the apnea-hypopnea index (AHI), body mass index, and comorbidities, but this classification has not been associated with differences in prognosis. An earlier study published by our group in patients with a severe form of OHS, in which global respiratory failure was detected at diagnosis, found a 5-year mortality rate of 15.5%, and a 2-fold risk of death compared to patients with SAHS without diurnal hypoventilation.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">4</span></a> Similarly to other studies,<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">5–7</span></a> the main cause of death was cardiovascular disease (CVD).</p><p id="par0010" class="elsevierStylePara elsevierViewall">Masa et al. classified OHS patients in tertiles according to the number of desaturations of ≥3% per hour of recording (oxygen desaturation index, ODI). Although it differs from the AHI, the ODI should reflect the severity of the underlying SAHS, and a higher prevalence of CVD could be expected among patients with more severe SAHS, but the authors found exactly the opposite.<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a> They speculated that this may be because patients with more severe disease might seek medical intervention earlier, and so would receive earlier treatment for their cardiovascular risk factors. They also referred to a mechanism called “ischemic preconditioning”, in which repeated episodes of subclinical ischemia, triggered by nocturnal hypoxemia, may lead to angiogenic stimulation and the development of collateral circulation. Aside from this, the study shows that the stratification of OHS is associated with significant clinical consequences. However, no difference was made between patients with and without SAHS, who could constitute different phenotypes. Ojeda et al.,<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> in contrast, did distinguish between OHS with and without SAHS, and identified more OHS patients without SAHS (OHS-nonSAHS) than with SAHS (OHS-SAHS). This study found no differences in mortality between the 2 groups (about 28% at 5 years), but a trend toward improved survival in OHS-SAHS was identified. The study was criticized for not reporting cardiovascular comorbidities in both groups before and after treatment, since this might explain the improved (but non-significant) survival among the OHS-SAHS group.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Our group designed a retrospective chart review to compare the prognosis of OHS-SAHS and OHS-nonSAHS patients (approved by the Ethics Committee of Galicia: Reg. No. 2017/079). We reviewed the medical records of 124 patients diagnosed with OHS between 1995 and 2017 using restrictive criteria: global respiratory failure at time of diagnosis and pH ≥ 7.34. Patient were matched 1:2 by date of diagnosis ±3 years, sex, and an age range of ±10 years. A total of 11 patients with OHS-nonSAHS (AHI<5) and 22 with OHS-SAHS were finally included. At baseline, there were no significant differences between patients with OHS-nonSAHS and OHS-SAHS in mean age (67 vs 68.5 years; <span class="elsevierStyleItalic">P</span>=.88), female sex (77.7% vs 77.1%; <span class="elsevierStyleItalic">P</span>=.1), average body mass index (43<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span> vs 42.5<span class="elsevierStyleHsp" style=""></span>kg/m<span class="elsevierStyleSup">2</span>; <span class="elsevierStyleItalic">P</span>=.81), FVC (59.5% vs 49% predicted; <span class="elsevierStyleItalic">P</span>=.96), baseline PaO<span class="elsevierStyleInf">2</span> (51.5±9.5<span class="elsevierStyleHsp" style=""></span>mmHg vs 48±7.6<span class="elsevierStyleHsp" style=""></span>mmHg; <span class="elsevierStyleItalic">P</span>=.25) and baseline PaCO<span class="elsevierStyleInf">2</span> (54.7±9.1<span class="elsevierStyleHsp" style=""></span>mmHg vs 60.6±13.2<span class="elsevierStyleHsp" style=""></span>mmHg; <span class="elsevierStyleItalic">P</span>=.38). Obviously, AHI was greater in OHS-SAHS patients with in OHS-nonSAHS individuals (4 vs 30; <span class="elsevierStyleItalic">P</span><.001), as was the desaturation index ≥4% per hour of nighttime recording (14 vs 41; <span class="elsevierStyleItalic">P</span><.001). There were no differences in time with SaO<span class="elsevierStyleInf">2</span><90% (95.5% vs 89%; <span class="elsevierStyleItalic">P</span>=.162). No significant differences were found in the prevalence of hypertension (72.7% in OHS-nonSAHS vs 95.4% in OHS-nonSAHS), diabetes (27.2% vs 36.3%), dyslipidemia (38.3% vs 50%), smoking (9.1% vs 13.6%), ischemic heart disease (9.1% vs 13.6%), heart failure (9.1% vs 22.7%), arrhythmias (0% vs 31.8%), cerebrovascular accidents (0% vs 4.55%) and atheromatosis (0% vs 4.5%) at the time of diagnosis, although there was a greater history of CVD in the OHS-SAHS group, which in a larger sample might have reached statistical significance. Mean follow-up was 5.4±1.5 years. All patients in the OHS-nonSAHS group received non-invasive mechanical ventilation (BiPAP, with additional oxygen in 7/11 cases), as did the majority of the OHS-SAHS patients (BiPAP initially in all, and after titration: BiPAP in 16/22, with additional oxygen in 15 and CPAP in 6 cases). There were no significant differences between OHS-nonSAHS and OHS-SAHS in the final determination of arterial blood gases: PaO<span class="elsevierStyleInf">2</span>: 65±9.6<span class="elsevierStyleHsp" style=""></span>mmHg vs and 72±11.6<span class="elsevierStyleHsp" style=""></span>mmHg, respectively (<span class="elsevierStyleItalic">P</span>=.10); PaCO<span class="elsevierStyleInf">2</span>: 44.3±2.5<span class="elsevierStyleHsp" style=""></span>mmHg vs 43.2±3.3<span class="elsevierStyleHsp" style=""></span>mmHg (<span class="elsevierStyleItalic">P</span>=.328). No significant differences were observed in mortality and cardiovascular events during follow-up, but there was a clear trend toward a higher incidence of both in the OHS-SAHS group (<a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>). Causes of death were CVD (6 in OHS-SAHS), cancer (1 in OHS-nonSAHS and 2 in OHS-SAHS), and sepsis (1 in OHS-SAHS). The main limitations of this study are its retrospective nature and small sample size (although all large series reflect the difficulty of finding patients with OHS without SAHS, so 11 patients constitute a reasonable sample).<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">4,10–12</span></a> Given the trend observed in our results, a larger sample would perhaps have demonstrated significant differences in mortality and CVD events, which could be explained by greater cardiovascular comorbidities in OHS-SAHS: no patient died of respiratory failure. These results diverge clearly from those of Masa<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">8</span></a> and Ojeda,<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">9</span></a> although they make sense if we consider that SAHS on its own is associated with significant endothelial dysfunction, CVD, and a greater risk of risk of cardiovascular death.<a class="elsevierStyleCrossRefs" href="#bib0140"><span class="elsevierStyleSup">13–15</span></a> OHS-SAHS and OHS-nonSAHS appear to be 2 different phenotypes of the disease, and only a multicenter prospective study, which may have to be international due to the above-mentioned difficulty in recruiting nonSAHS patients, will be able to identify differences in prognoses between the two.</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">Please cite this article as: Rodriguez Alvarez A, Méndez Marote L, Castro Añón O, Golpe Gómez R, Pérez de Llano LA. Pronóstico del síndrome de hipoventilación-obesidad con y sin síndrome de apnea obstructiva asociado. Arch Bronconeumol. 2018;54:230–231.</p>" ] ] "multimedia" => array:1 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:3 [ "leyenda" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">OHS: obesity hypoventilation syndrome; SAHS: sleep apnea-hyponea syndrome.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Data expressed in absolute frequencies and percentages.</p>" "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">OHS-nonSAHS (11) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">OHS-SAHS (22) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black"><span class="elsevierStyleItalic">P</span>-value<a class="elsevierStyleCrossRef" href="#tblfn0005"><span class="elsevierStyleSup">a</span></a> \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Death \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1 (9.1) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 (40.9) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.108 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Cardiovascular events \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">4 (36.3) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10 (45.4) \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">.719 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1720485.png" ] ] ] "notaPie" => array:1 [ 0 => array:3 [ "identificador" => "tblfn0005" "etiqueta" => "a" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Values calculated with Fisher's exact test.</p>" ] ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Number of Deaths and Cardiovascular Events by Groups.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:15 [ 0 => array:3 [ "identificador" => "bib0080" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Grading obesity hypoventilation syndrome severity" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "C. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 10 | 3 | 13 |
| 2024 October | 70 | 23 | 93 |
| 2024 September | 65 | 14 | 79 |
| 2024 August | 84 | 33 | 117 |
| 2024 July | 58 | 27 | 85 |
| 2024 June | 64 | 27 | 91 |
| 2024 May | 87 | 29 | 116 |
| 2024 April | 56 | 35 | 91 |
| 2024 March | 65 | 21 | 86 |
| 2024 February | 61 | 35 | 96 |
| 2023 April | 1 | 0 | 1 |
| 2023 March | 14 | 9 | 23 |
| 2023 February | 88 | 28 | 116 |
| 2023 January | 98 | 35 | 133 |
| 2022 December | 76 | 25 | 101 |
| 2022 November | 105 | 35 | 140 |
| 2022 October | 98 | 35 | 133 |
| 2022 September | 93 | 31 | 124 |
| 2022 August | 83 | 50 | 133 |
| 2022 July | 106 | 45 | 151 |
| 2022 June | 95 | 36 | 131 |
| 2022 May | 114 | 43 | 157 |
| 2022 April | 137 | 37 | 174 |
| 2022 March | 145 | 44 | 189 |
| 2022 February | 143 | 31 | 174 |
| 2022 January | 140 | 38 | 178 |
| 2021 December | 110 | 46 | 156 |
| 2021 November | 108 | 40 | 148 |
| 2021 October | 125 | 51 | 176 |
| 2021 September | 113 | 46 | 159 |
| 2021 August | 84 | 46 | 130 |
| 2021 July | 81 | 49 | 130 |
| 2021 June | 87 | 34 | 121 |
| 2021 May | 117 | 58 | 175 |
| 2021 April | 207 | 109 | 316 |
| 2021 March | 146 | 34 | 180 |
| 2021 February | 87 | 34 | 121 |
| 2021 January | 60 | 13 | 73 |
| 2020 December | 56 | 25 | 81 |
| 2020 November | 45 | 27 | 72 |
| 2020 October | 53 | 14 | 67 |
| 2020 September | 54 | 11 | 65 |
| 2020 August | 36 | 14 | 50 |
| 2020 July | 37 | 23 | 60 |
| 2020 June | 44 | 10 | 54 |
| 2020 May | 44 | 9 | 53 |
| 2020 April | 47 | 19 | 66 |
| 2020 March | 23 | 9 | 32 |
| 2020 February | 54 | 22 | 76 |
| 2020 January | 56 | 9 | 65 |
| 2019 December | 73 | 19 | 92 |
| 2019 November | 65 | 23 | 88 |
| 2019 October | 63 | 19 | 82 |
| 2019 September | 71 | 19 | 90 |
| 2019 August | 68 | 27 | 95 |
| 2019 July | 43 | 16 | 59 |
| 2019 June | 37 | 18 | 55 |
| 2019 May | 57 | 23 | 80 |
| 2019 April | 77 | 24 | 101 |
| 2019 March | 59 | 28 | 87 |
| 2019 February | 45 | 18 | 63 |
| 2019 January | 43 | 25 | 68 |
| 2018 December | 65 | 20 | 85 |
| 2018 November | 44 | 29 | 73 |
| 2018 October | 78 | 26 | 104 |
| 2018 September | 3 | 0 | 3 |
| 2018 April | 1 | 1 | 2 |
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