Respiratory issues in Gastroenterology

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Respiratory issues in Gastroenterology

• Najmuddin S. Patwa M.D.
• Pulmonary and Sleep Medicine
• Stoneham Medical Group
• Director, Winchester Hospital Sleep Disorders
  Center

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Winchester Hospital Sleep Disorders Center
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Obama-esque agenda (the first 100 minutes)

• Recap sleep disorders and relevance to patient
  care in the endoscopy unit
• Understanding COPD the ACU
• Respiratory pathophysiology in liver disease
• Sleep and respiratory problems in the management
  of the hepatitis C patient

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The Natural Cycle
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Sleeping should be simple
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The bed partner
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Anatomy of snoring
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Anatomy of Sleep Apnea
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Anatomy of Sleep Apnea
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Statistics

• Prevalence 10 million Americans have been
  diagnosed with sleep apnea
• 20-30 million Americans are estimated to have
  sleep apnea---UNDIAGNOSED
• 1-3 of children
• 12-24 of adult men 4-9 adult women
• increasing prevalence in womenincreased
  awareness
• Sevenfold increase in involvement in auto
  accidents

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Common Symptoms

• Loud snoring
• Excessive daytime sleepiness
• High blood pressure and other cardiovascular
  complications
• Morning headaches

• Feelings of depression
• Reflux
• Nocturia
• Impotence
• Memory problems

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Risk Factors for Sleep Apnea

• A family history of sleep apnea
• Excess weight
• A large neck
• A recessed chin
• Male sex
• Sleep labs 61 MF, real world 21
• Abnormalities in the structure of the upper
  airway
• Smoking
• Alcohol use
• Age

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DIAGNOSING SLEEP APNEA
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CPAPContinuous positive airway pressure
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CPAP
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CPAPContinuous positive airway pressure
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CPAP
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Surgery for sleep apnea
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Why Treat OSA ?
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AASM RECOMMENDATIONS

• HIGH INDEX OF SUSPICION
• CONSTANT MONITORING OF THE AIRWAY
• JUDICIOUS USE OF MEDICATIONS
• PROPER POST OP MONITORING

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CONSIDERATIONS IN THE ACU

• PREOPERATIVE ASSESSMENT
• SEDATION
• MONITORING INTRAOPERATIVELY
• POST PROCEDURE MONITORING

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PREOPERATIVE ASSESSMENT

• HISTORY- WHEN BOOKING
• SLEEP DISORDER
• BMI
• CPAP USE
• SURGICAL HX---UPPP
• CO-MORBID CONDITIONS
• MEDICATION SENSITIVITIES
• EXAM-on arrival or office visit
• AIRWAY GRADING
• JAW ANATOMY
• PULSE OXIMETRY/CAPNOGRAPHY

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SEDATIONMEDICATION CHOICES

• OPIATES-
• BENZODIAZEPINES
• PREMEDICATIONANTICHOLINERGICS
• PROPOFOL
• BARBITURATES
• KETAMINE
• TOPICAL ANESTHESTICS

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MONITORING STANDARDS For SEDATION

• PULSE OXIMETRY/ CAPNOGRAPHY
• OBSERVATION--telemetry
• CHEST AND ABDOMINAL MOVEMENTS
• BLOOD PRESSURE
• ARRHYTHMIAS
• INTUBATION SET-UP
• 22 OF OSA PATIENTS DIFFICULT ETT
• 2.6 OF NON-OSA PATIENTS

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POST PROCEDURE MONITORING

• SAME AS DURING SEDATION
• DONT RELAX
• APPLICATION OF CPAP DURING RECOVERY
• WARN PATIENT ON DISCHARGE
• NEGATIVE PRESSURE PULMONARY EDEMA

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COPD and Co-Morbidities

• COPD patients are at increased risk for
• Myocardial infarction, angina
• Osteoporosis
• Respiratory infection
• Depression
• Diabetes
• Lung cancer

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Definition of COPD

• COPD is a preventable and treatable disease with
  significant extrapulmonary effects that
  contribute to the severity in individual
  patients.
• pulmonary component is characterized by airflow
  limitation that is not fully reversible.
• The airflow limitation is usually progressive and
  associated with an abnormal inflammatory response
  of the lung to noxious particles or gases.

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Classification of COPD Severity by Spirometry
Stage I Mild FEV1/FVC FEV1 80 predicted Stage II Moderate
FEV1/FVC 50 FEV1/FVC 30 Severe FEV1/FVC chronic respiratory failure
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Percent Change in Age-Adjusted Death Rates, U.S.,
1965-1998
Proportion of 1965 Rate
3.0
Coronary Heart Disease
Stroke
Other CVD
COPD
All Other Causes
2.5
2.0
1.5
1.0
0.5
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64
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163
7
0
1965 - 1998
1965 - 1998
1965 - 1998
1965 - 1998
1965 - 1998
Source NHLBI/NIH/DHHS
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COPD Mortality by Gender,U.S., 1980-2000
Number Deaths x 1000
Source US Centers for Disease Control and
Prevention, 2002
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Risk Factors for COPD

• Genes
• Exposure to particles
• Tobacco smoke
• Occupational dusts, organic and inorganic
• Indoor air pollution from heating and cooking
  with biomass in poorly ventilated dwellings
• Outdoor air pollution

Lung growth and development Oxidative
stress Gender Age Respiratory infections Socioecon
omic status Nutrition Comorbidities
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Risk Factors for COPD
Nutrition
Infections
Socio-economic status
Aging Populations
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ASTHMA
Allergens
Mast cell
Ep cells
CD4 cell (Th2)
Eosinophil
Bronchoconstriction AHR
Airflow Limitation
Reversible
Irreversible
Source Peter J. Barnes, MD
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GOALS of COPD MANAGEMENT VARYING EMPHASIS WITH
DIFFERING SEVERITY

• Relieve symptoms
• Prevent disease progression
• Improve exercise tolerance
• Improve health status
• Prevent and treat complications
• Prevent and treat exacerbations
• Reduce mortality

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COPD and Co-Morbidities

• COPD has significant extrapulmonary
• (systemic) effects including
• Weight loss
• Nutritional abnormalities
• Skeletal muscle dysfunction

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IV Very Severe
III Severe
II Moderate
I Mild
Add regular treatment with one or more
long-acting bronchodilators (when needed) Add
rehabilitation
Add inhaled glucocorticosteroids if repeated
exacerbations
Add long term oxygen if chronic respiratory
failure. Consider surgical treatments
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Portable oxygen
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Indications for Oxygen Therapy

• PaO2 55 mmHg or SaO2 88
• In the presence of cor pulmonalePaO2 59 mmHg or
  SaO2 89
• EKG evidence of P pulmonale
• Hematocrit 55
• Clinical evidence of right heart failure
• If the patient is normoxemic at rest but
  desaturates during exercise or sleep (PaO2 55
  mmHg),
• sleep apnea with nocturnal desaturation not
  corrected by CPAP.
• Consideration of nasal continuous positive airway
  pressure (CPAP) or bi-level noninvasive nocturnal
  ventilation is warranted in patients with
  desaturation during sleep.

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Long-term Oxygen Therapy
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Long-term Oxygen Therapy
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GOALS OF NONINVASIVE VENTILATION

• Short-term (including acute)  
• Relieve symptoms
• Reduce work of breathing  
• Improve or stabilize gas exchange
• Optimize patient comfort 
• Good patient-ventilator synchrony
• Minimize risk 
• Avoid intubation

• Long-term 
• 1. Improve sleep duration and quality  
• 2. Maximize quality of life 
• 3. Enhance functional status  
• 4. Prolong survival

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Considerations for the endoscopy unit

• Proper history of respiratory disease
• Functional capacity
• Recent exacerbations
• Medications
• Inhalers
• Nebulizers
• Theophylline
• Oxygen use
• CPAP/BIPAP

• On site care
• Oxygen administration
• monitoring
• Sedation
• Post procedure considerations

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Prevalence of Hepatopulmonary syndrome

• viral hepatitis with or without cirrhosis
  prevalence of HPS 10
• HPS in OLT candidates 18
• 28 in Budd-Chiari syndrome.(hepatic vein
  occlusion)
• median survival of 24 months a 5-year survival
  rate of 23 (not candidates for liver
  transplantation )
• median survival of 87 months, with a 5-year
  survival rate of 63 without PHS

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Potential co-existent conditions

• COPD
• Interstitial lung disease
• Asthma
• Heart disease

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Exam findings
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RLS Associated Co morbidities in CLD

• Kidney Disease 64.7 ( 23.8)
  Absent12462.1 ( 8.9)
• Anemia Present 68.1 ( 14) Absent 59.6 (
  10.3)
• Iron Deficiency Present 64.5 ( 17.5)
  Absent 61.2 ( 9.4)
• Neuropathy Present 85.2 ( 14.8) Absent
  57.0 ( 9.5)
• Medications or other (Dopamine antagonist,
  alcohol use, antihistamines etc.) Present
  68.6 ( 13.4) Absent 60.0 ( 10.9)
• Editted fromJ Clin Sleep Med. 2008 February 15
  4(1) 4549.

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Mechanisms of Arterial Hypoxemia in the
Hepatopulmonary Syndrome in a Two-Compartment
Model of Gas Exchange in the Lung
Rodríguez-Roisin R, Krowka M. N Engl J Med
20083582378-2387
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Hepatopulmonary syndromepathophysiology

• Clinical findings
• Hyperventilation
• Exercise intolerance
• Orthodeoxia
• Sleep disturbance
• Respiratory alkalosis
• False readings on pulse oximetry

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Diagnostic Criteria for the Hepatopulmonary
Syndrome
Rodríguez-Roisin R, Krowka M. N Engl J Med
20083582378-2387
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Hepatopulmonary syndromepathophysiology

• mechanisms
• Intrapulmonary shunt
• Porto-systemic shunt
• Altered cardiac function
• Anemia

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Diagnostic testingfor shunt detection

• Contrast enhanced echocardiogram
• Bubble study
• Ventilation-perfusion scan
• Early uptake in kidneys, liver
• Arterial blood gas
• Shunt fraction increased
• Typically with respiratory alkalosis
• Advanced stage disease may have metabolic
  acidosis
• Graded by severity of hypoxemia

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Transthoracic Echocardiographic Features of the
Hepatopulmonary Syndrome
Rodríguez-Roisin R, Krowka M. N Engl J Med
20083582378-2387
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Findings of Hepatopulmonary Syndrome on Lung and
Brain Scans
Rodríguez-Roisin R, Krowka M. N Engl J Med
20083582378-2387
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Differential Diagnosis and Treatment of Pulmonary
Vascular Disorders Associated with Hepatic
Abnormalities
Rodríguez-Roisin R, Krowka M. N Engl J Med
20083582378-2387
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Major Pulmonary Consequences in Patients with
Advanced, Nonmalignant Liver Disorders
Rodríguez-Roisin R, Krowka M. N Engl J Med
20083582378-2387
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Additional testing for Hepatopulmonary syndrome

• Chest x-ray
• CT scan
• Contrast enhanced
• Pulmonary function testing
• Likely good idea in Hepatitis C pre-treatment

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Recommendations for Hepatopulmonary syndrome
(HPS)

• Screen for HPS using arterial blood gas levels in
  hepatic patients
• who
• complain of dyspnoea,
• 2) are OLT candidates
• Proceed to CEE if
• Pa,O2v80 mmHg,
• and/or PAa,O2 o15 mmHg
• Diagnosis of HPS must be completed with
• 1) PFTs,
• 2) thoracic HRCT scan
• 3) 99mTcMAA shunting index (if available)
• long-term oxygen therapy
• Consider firm indication for OLT if Pa,O2 o50v60
  mmHg OLT
• should be considered on an individual basis if
  Pa,O2
• 5-year survival rate of 76 after liver
  transplantation

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Hepatitis C therapy

• (Wiki def.) Interferons (IFNs) are natural
  proteins produced by the cells of the immune
  system of most vertebrates in response to
  challenges by foreign agents such as viruses,
  parasites and tumor cells. Interferons belong to
  the large class of glycoproteins known as
  cytokines. Interferons are produced by a wide
  variety of cells in response to the presence of
  double-stranded RNA, a key indicator of viral
  infection. Interferons assist the immune response
  by inhibiting viral replication within host
  cells, activating natural killer cells and
  macrophages, increasing antigen presentation to
  lymphocytes, and inducing the resistance of host
  cells to viral infection

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Interferons

• Alpha
• Hepatitis C
• Malignancies
• Skin cancers
• Beta
• Multiple sclerosis
• Gamma
• Pulmonary fibrosis---an interesting experience

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Pulmonary symptoms with Hepatitis c therapy

• including dyspnea
• pulmonary infiltrates
• pneumonitis
• pneumonia
• cases of fatal pneumonia have occurred.
• sarcoidosis or exacerbation of sarcoidosis has
  been reported

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Psychiatric adverse eventsin Hepatitis C Therapy

• depression
• psychoses
• aggressive behavior
• Hallucinations
• suicidal ideation, suicidal attempts, suicides
• violent behavior (rare instances of homicidal
  ideation have occurred)

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PEGASYS and COPEGUS

• fatigue/asthenia (65)
• headache (43)
• pyrexia (41)
• myalgia (40)
• irritability/anxiety/nervousness (33)
• insomnia (30)
• alopecia (28)
• neutropenia (27)

• nausea/vomiting (25)
• rigors (25)
• anorexia (24)
• injection-site reaction (23)
• arthralgia (22)
• depression (20)
• pruritus (19)
• dermatitis (16).

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Why do you use this stuff?

• Cure rates for interferon therapy 50-75 For
  hepatitis C in conjunction with Ribaviran

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Winchester Hospital Sleep Disorders Center
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• Ischemic hepatitis due to obstructive sleep
  apneaGastroenterology, Volume 109, Issue 5,
  Pages 1682-1684

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Sleep disorders in Hepatitis C

• Carlson M, Baraket F, Richards L, et al. Sleep
  and fatigue in patients with chronic hepatitis C.
  Hepatology. 200440248A. Abstract 190