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EVEN WHEN THE TREATMENT WORKS, UNKNOWLEDGE IS A BIG PROBLEM: AN OBESITY-HYPOVENTILATION SYNDROME CASE REPORT
Obesity Hypoventilation Syndrome (OHS) is defined as the presence of obesity (BMI ≥ 30 kg/m²) and daytime arterial hypercapnia (PaCO2 ≥ 45 mmHg), in the absence of other causes of hypoventilation. One third of obese patients admitted to internal medicine services may have OHS. OHS is often neglected or misdiagnosed as other causes of hypoventilation, especially COPD. The importance of recognizing OHS is a high morbidity and mortality, if not treated.
We report a case of OHS in which, despite previous treatment improvement, the lack of syndrome’s diagnosis led to further worsening.
Woman, 47 years-old, admitted in the ER due to dyspnea and cough with sputum. Her husband referred a history of snoring, nocturnal gasping and daytime sleepiness. She had hypertension, was non-smoker, without previous respiratory symptoms or risk exposures. About 30 days before, presented an episode of progressive dyspnea, evolving to acute respiratory failure (ARF). In that moment, it was performed an early tracheostomy, with significant improvement and quick discharge from ICU. Nearly 9 days before, the tracheostoma was closed. She had respiratory distress and BMI = 50 kg/m² at the physical examination. A case of pneumonia was diagnosed in the ward, and antibiotics were initiated, with laboratorial improvement but clinical worsening. As it evolved to ARF, the patient then was transferred to the ICU. Previous arterial blood gas analysis presented PCO2 = 52,4mmHg and Bicarbonate=29,7 mmol/L. There was a clinical and respiratory improvement just after intubation and mechanical ventilation, with PCO2 = 42,5mmHg. A tracheostomy was redone and was the treatment option due to social and healthcare limitations, being stable during the follow-up at the outpatient clinic.
We report an OHS case that underwent tracheostomy due to ARF. After discharge, the tracheostomy was reversed without any additional measures, which led to further worsening. The importance of identifying OHS is due to the high mortality in untreated patients. Treatment aims to normalize ventilation during sleep. In 90% of the cases, it is associated with Obstructive Sleep Apnea (OSA). Tracheostomy, the first treatment reported, is now considered a last option. The treatment of choice is the use of continuous positive airway pressure (CPAP) as it mitigates obstructive events.
Obesity-Hypoventilation Syndrome, Tracheostomy; Diagnosis
Relato de Caso
Centro Universitário Pessoense - Paraiba - Brasil
Caroline Cardoso Costa, Rodolfo Augusto Bacelar Athayde, Ianna Cristhina Palitot Remigio Leite, Cecília Regina Bastos Santos, Gustavo Soares Fernandes, Roberta Tavares Souza Barreto, Thiago Henrique Fernandes Carvalho