Internal Medicine

Disorders of Ventilation and Sleep Disorders

Disorders of Ventilation
Hypoventilation
Hyperventilation
Alveolar hypoventilation
o Hallmark: Increases in alveolar
PCO2 (PACO2) level and
therefore arterial PCO2
(PACO2).
o It exists when arterial PCO2
(PaCO2) increases above the
normal range of 37-43mmHg.
o The increase in PaCO2 produces
obligatory decrease in PaO2
resulting in hypoxemia.
o Acute or chronic
Chronic Hypoventilation Syndrome
Mechanism Site of defect Disorders
Impaired
respiratory
drive

























Peripheral and
central
chemoreceptors







Brainstem
respiratory
neurons















Carotid body
dysfunction
trauma

Prolonged
hypoxia

Metabolic
alkalosis

Bulbar
poliomyelitis
encephalitis

Brainstem
infarction
hemorrhage,
trauma

Brainstem
demyelination,
degeneration

Chronic drug
administration

Hypothyroidism
Primary





Defective
respiratory
neuromuscular
system

















Impaired
ventilator
apparatus






Spinal cord and
peripheral
nerves








Respiratory
muscles








Chest wall











Airway and
Lungs
alveolar
hypoventilation
syndrome


High cervical
trauma

Poliomyelitis

Motor neuron
disease

Peripheral
neuropathy

Myasthenia
gravis

Muscular
dystrophy

Chronic
myopathy


Kyphoscoliosis

Fibrothorax

Thoracoplasty

Ankylosing
spondylitis

Obesity
hypoventilation

Laryngeal and
tracheal
stenosis

Obstructive
sleep apnea

Cystic fibrosis

Chronic
obstructive
pulmonary
disease


Primary Secondary Clinical Feature
physiological physiological
event even
































Primary alveolar hypoventilation
Disorder of unknown cause
Characterized by chronic hypercapnia
and hypoxemia
Absence of identifiable neuromuscular
disease or mechanical ventilatory
impairment
Males age 20-50y/o
Develops insidiously
Severe respiratory depression following
administration of standard sedative or
anesthetics
Dyspnea is uncommon despite abg
derangements presumably because of
impaired chemoreception and
venilatory drive
Lethargy, fatigue, daytime somnolence,
disturbed sleep, morning headaches
Cyanosis, polycythemia, pulmonary
hypertension, congestive heart failure
May be fatal
Diagnosis
Chronic respiratory acidosis in the
absence of respiratory muscle
weakness or impaired ventilatory
mechanics
Elevated plasma HCO3-level
Normal ventilatory mechanics and
respiratory strength
Ventilatory responses to chemical
stimuli are ??? or absent
Management
Caution on the use of sedatives
Respiratory stimulant medications
Supplemental O2
Mechanical ventilatory assistance
Diaphragmatic pacing by electrophrenic
stimulation
Negative or positive pressure
ventilation especially during sleep
Respiratory Neuromuscular Disorders
Primary disorders of the spinal cord,
peripheral respiratory nerves, and
respiratory muscles
Gradual development of chronic
hypoventilation unless there is
significant weakness of the diaphragm
Orthopnea, paradoxical movement of
the abdomen in supine position,
paradoxical diaphragmatic movement
under fluoroscopy
Diagnosis
Fall in forced vital capacity in supine
posture
Rapid deterioration of ventilation
during maximum voluntary ventilation
maneuver
Reduced P Imax and P Emax
PaCO2
pH

PaO2
Cerebral
vasodilation
Arousals
from sleep
Hb
Desaturation

erythropoiesis

Pulmonary
vasoconstriction
Morning
headache
Disturbed
sleep
Daytime
somnolence
Confusion,
fatigue


Cyanosis
polycythemia
Pulmonary
hypertension
Congestive
heart failure
HCO3-
Cl-
Reduced or absent transdiaphragmatic
pressures

Reduced diaphragm response to
transcutaneous phrenic nerve
stimulation
Marked hypopnea and desaturation
during REM sleep
Management
Treat the underlying cause
Mechanical ventilatory assistance
Electrophrenic diaphragmatic
stimulation is contraindicated
Obesity Hypoventilation Syndrome
Marked obesity represents a
mechanical load to the respiratory
system
Decreased central respiratory drive
Obstructive sleep apnea
Sleep induced hypoventilation
Diagnosis
Reduced compliance of the chest wall
Reduced functional residual capacity in
recumbent position
Low lung volume at the base
Management
Weight reduction
Smoking cessation
Elimination of OSA
Enhancement of respiratory drive by
medication such as progesterone