Understanding of respiration in human. Impact of obesity and diseases arising out of it. Relevance of identifying it early and its management

1. Obesity and Respiration - Dr. Parthiv Mehta
Obesity
and
RESPIRATION
Dr. Parthiv MEHTA
Central UNITED Hospital
Ahmedabad

2. GOAL
• Increase awareness towards Obesity
• Understand Obesity related
Respiratory Disorder - Sleep Apnoea –
with reference to risks if untreated
• Educate / Revise recognizing,
preventing and treating Sleep Apnoea

3. • Definition….
Obesity

4. 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

5. www.bmi3d.com

6. • Scientists have identified SNP (single nucleotide
polymorphism) named “rs12970134” to be mostly
associated with waist circumference.
• Over 2000 individuals of Indian origin participated
and SNP “rs12970134” is found highly prevalent.
• Internationally, a BMI over 25 kg/m2 is considered
overweight. Due to genetic tendency of Indians
towards abdominal obesity and its associated risk
of related lifestyle diseases like Diabetes & Heart
Disease,
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

7. Obesity - INDIA
• Obesity has reached epidemic
proportions in India, with morbid
obesity affecting 5% of the country's
population.
Male Female
India Gujarat India Gujarat
12.1 15.4 16.0 17.7

8. Obesity - INDIA

9. Obesity

10. 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

11. Human Lung…

12. Human Lung…

13. Human Lung…

14. Respiration:
Air - In and Out of Lungs

15. I’m Thin, My Lungs are Happy..

16. I’m Moderate…Lungs feel OK..

17. Oh dear…I’m Compressed..

18. Obesity and Respiration - Dr. Parthiv Mehta
See the Difference…

19. Our Nose & Throat…

20. Our Nose & Throat…

21. Our Nose & Throat…

22. Our Nose & Throat…

23. Our Nose & Throat…

24. With Obesity…
FAT

25. 079 26854849

26. 079 26854849

27. 079 26854849

31. While asleep…

32. Obesity and Respiration - Dr. Parthiv Mehta
FLOW
TIME
Open Airway

33. Obesity and Respiration - Dr. Parthiv Mehta
Flow Limitation
TIME
FLOW

34. While asleep…SNORING…

35. Obesity and Respiration - Dr. Parthiv Mehta
Snore
FLOW
TIME

36. Severe Cases….AWAKENING..

37. Obesity and Respiration - Dr. Parthiv Mehta
Apnea
TIME
FLOW

38. Sleep Apnoea - Mechanism
• During sleep
– When the muscles at the back of the
airway relax and the upper airway
partially or completely collapses
– Leads to obstruction in breathing and
restricts airflow.
• Snoring is a common symptom of SA.
Every Snorer may not be Apnoeic

39. Sleep Apnoea - Mechanism

40. Sleep Apnoea
• Sleep Apnoea (SA) is disordered breathing
during sleep.
• The airway is mechanically obstructed
causing a cessation of breathing - OSA.
• An apnoea occurs when a person stops
breathing for 10 seconds or more.
• If untreated can lead to Cardiovascular
and Cerebro-vascular disease and Injury
from vehicular accidents because of
sleepiness.

41. 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

42. 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 neck
muscles to loose tone and collapse when
lying supine
Crowded teeth and narrow palate in
children

43. Sleep Apnoea – Existence..

44. 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.

45. 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 then
inspiration fails to overcome the resistance in the
pharynx - of which stridor or snoring is the audible sign,
• and there will be perfect silence through two, three, or
four respiratory periods, in which there are ineffectual
chest movements;
• finally, air enters with a loud snort, after which there
are several compensatory deep inspirations before the
breathing settles down to its usual rhythm..”
Sleep Apnoea – Existence..

46. Why Don’t Animal Get it??

47. Why Don’t Animal Get it??

48. Why Don’t Animal Get it??

49. Sleep Apnoea - Burden
• 42 million Americans suffer from OSA
– Found across all age groups, both sexes,
all socioeconomic classes and ethnic
groups
– Most common in obese middle-aged men
and obese postmenopausal women
• 4-9% of Population in INDIA fall in High
Risk group
Young et al. Sleep 2008

50. Sleep Apnoea – Effect on Body
During an apnoea At the end of an apnoea
Oxygen levels begin to
decrease
Oxygen “recovers” upon
arousal (though this may
take several minutes)
Heart rate slows Dramatic rise in heart rate
Blood pressure drops
Dramatic rise in blood
pressure

51. Sleep Apnoea –A Common Companion
Diabetes
Obesity
All Hypertension
Atrial Fibrillation
Congestive
Heart Failure
Drug-Resistant
Hypertension
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

52. Sleep Apnoea –A Common Companion
Diabetes
Obesity
All Hypertension
Atrial Fibrillation
Congestive
Heart Failure
Drug-Resistant
Hypertension
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

53. Sleep Apnoea – Impact on Heart
Postgrad Med J 2008; 84:15-22

54. Sleep Apnoea – Impact on Heart
High Blood Pressure – All cause Hypertension
• 3 times higher risk to develop High Blood
pressure
• ~40% of people with OSA have high blood
pressure while awake
Heart Attack – Ischaemia / Infarction
• 36% of patients with OSA had Fatal or Non fatal
event.
• Sudden death from cardiac causes (between
midnight and 6 am) occurred in 46% of pts with
OSA v/s 16% of general population
Sleep Apnea is an
identifiable cause of
hypertension
according to the
National Institute of
Health (NIH)

55. Sleep Apnoea – Impact on Heart
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 with
OSA occur at night (8pm-8am)
• AF recurrence after cardio-version twice as high in
untreated OSA

56. Sleep Apnoea – Impact of Treatment
High Blood Pressure:
• Proven benefits from sleep apnoea therapy in
lowering blood pressure
– 4mm Hg to 10mm Hg reduction with CPAP therapy
• Study showed a fall in systolic BP by 10 mm
after 4 weeks of CPAP
• Improvement in blood pressure correlated
with improvement / reduction in sleepiness.
Becker et al. Circulation 2003

57. Sleep Apnoea – Impact of Treatment
Cardiac Failure:
• Proven benefits from sleep apnoea therapy in
improving cardiovascular health
– Left ventricular ejection fraction, six-minute walk,
VO2 max, after load, BNP
Kaneko 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; 84:15-22
Proc Am Thorac Soc 2008; 5:200-206

58. Sleep Apnoea – IMPACT of AWARENESS
• Widespread public awareness resulted into
an 80% increase of newly diagnosed cases of
OSA over the next 24 months
• With the initiation of early therapy,
morbidity and mortality rates due to related
cardiovascular disease in the at risk
population reduced by 60% within the next
48 months.
healthypeople.org. Healthy People 2010. Retrieved November 17, 2003, ProQuest

60. Let us Recap…..Obesity
SLEEP, Vol. 30, No. 3, 2007

61. 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
Increased
Accidents:
Road Traffic
Work place
Stroke
Obstructive
Sleep
Apnoea

62. Take Home Message…
• There is a clear association between
Obesity, OSA and cardiovascular disease
• Higher incidence of adverse
cardiovascular events in untreated
patients with Obesity and OSA
• Early Detection and Treatment helps to
eliminate potential Cardio-Vascular Risks
and reduces morbidity and mortality.
Postgrad Med J 2008; 84:15-22 SLEEP 2007;30(3):291-304
CHEST 2008; 133:793-804 Proc Am Thorac Soc 2008; 5:200-206

63. If UNTREATED…..
Take Home Message…
Obesity with Sleep Apnoea can
SINK LIFE..

66. Further references…