1/23. Pickwickian syndrome: the challenge of severe sleep apnea. Pickwickian syndrome is a severe form of sleep apnea in obese persons which involves mechanical impairment of ventilation resulting in greatly compromised gas exchange. Manifestations of the syndrome are associated with deposits of adipose tissue around the abdomen and diaphragm and are completely reversible with weight loss. Since sleep apnea is now recognized as a significant chronic health problem, nurses in intensive care, medical-surgical, and home care settings are increasingly challenged to provide competent assessment, care, and rehabilitation of affected individuals. ( info) |
2/23. Hypersomnia with periodic breathing (an acromegalic Pickwickian). The syndromes of Pickwickian, Ondine's curse, and primary alveolar hypoventilation are respiratory disorders manifesting increased sleepiness and irregular respiratory rhythms. These disorders are currently grouped as hypersomnia with periodic breathing (HPB). Polygraphic techniques have lead to a reasonable hypothesis as to the pathophysiology of the multiple variants of HPB. Discernible causes of HPB have been attributed to both central and peripheral factors. Peripheral factors encompass those conditions relating to upper airway obstruction. An acromegalic person suffering the HPB syndrome secondary to laryngeal stenosis is described. ( info) |
3/23. Pickwickian syndrome, 20 years later. The Pickwickian syndrome stimulated new pathophysiological concepts in regard to control of ventilation. With the advent of sleep laboratories, the peculiar sleep apnea occurring in some of these patients has been explained on the basis of intermittent upper airway obstruction. Two patients with different manifestations of the Pickwickian syndrome are presented. The suggestion is made that these two subsyndromes should have unique designations. The Auchincloss syndrome is manifested by right heart failure and respiratory acidosis in obese patients who are alert and have no major abnormality of breathing pattern. The fundamental cause of this abnormality is the increased work of breathing caused by the obesity. The cost of breathing is so high that the ventilatory regulation is compromised and respiratory acidosis results. The Gastaut syndrome is characterized principally by hypersomnia and sleep apnea. The fundamental defect is upper airway obstruction during sleep, resulting in increased work of breathing, which together with the increased work caused by obesity leads to respiratory acidosis and right ventricular failure. Hypersomnia, rather than heart failure or respiratory acidosis, is the major manifestation of this syndrome, and is the result of sleep loss. ( info) |
| OBJECTIVE: The objective of this study was to alert critical care physicians to the syndrome of obstructive sleep apnea with respiratory failure ("near miss" death) and to elucidate characteristics that might allow earlier recognition and treatment of such patients. DESIGN: We examined clinical and laboratory characteristics of eight patients with obstructive sleep apnea presenting to the ICU with respiratory failure. These characteristics were compared with those of eight stable apnea patients of similar severity but without a history of presentation with respiratory failure. SETTING: Medical ICU and pulmonary outpatient clinic at the Houston veterans Administration Medical Center, a teaching hospital affiliated with Baylor College of medicine. PATIENTS: Eight patients with obstructive sleep apnea who presented in, or developed, acute respiratory failure requiring tracheal intubation and mechanical ventilation were matched to eight stable obstructive sleep apnea outpatients from the chest clinic. MEASUREMENTS AND MAIN RESULTS: The records of these 16 patients were reviewed and multiple characteristics that might predict these obstructive sleep apnea patients prone to respiratory failure and death (called the "near miss" death group; n = 8) were examined. The mean age of the near miss group was 57 yrs. All eight patients presented with respiratory acidosis (mean pH 7.22), hypercarbia (mean PaCO2 82 torr [10.9 kPa]), and hypoxemia (mean PaO2 45 torr [6.0 kPa]). Six of the eight patients had concomitant chronic obstructive pulmonary disease as determined by clinical characteristics and spirometry. Predisposing factors included facial trauma, lower respiratory tract infections or bronchospasm, and use of pain medication. All but one of the near miss subjects had awake hypercarbia (mean PaCO2 49 torr [6.5 kPa]) and hypoxemia (mean PaO2 58 torr [7.7 kPa]) during periods of clinical stability while only two controls had concomitant chronic obstructive pulmonary disease and none had hypercarbia. The prevalence of a history of wheezing and prior hospitalization for "respiratory problems" were greater in the near miss group. Once cured of apnea, no patient presented with recurrence of respiratory failure in follow-up ranging from 6 to 80 months, and cor pulmonale recurred in only one patient during subsequent onset of central apneas. CONCLUSION: Patients with obstructive sleep apnea who have concomitant chronic obstructive pulmonary disease or hypercarbia and hypoxemia are more prone to develop severe respiratory failure and probable death than those patients with apnea alone. The current study shows that recurrent respiratory failure and presumably mortality from this acute complication can be reversed with effective treatment of the obstructive apnea. ( info) |
| We have reported a case of spontaneous rupture of the stomach in an adult. Immediate onset of severe upper abdominal pain after overindulgence in food and drink along with radiographic evidence of pneumoperitoneum and the clinical findings of massive abdominal distention, epigastric tenderness, shock, and occasionally subcutaneous emphysema should suggest the possibility of gastric rupture. The treatment is simple, but mortality is high when surgical intervention is not rapid. ( info) |
6/23. Endoscopic findings in sleep apnea syndrome. Sleep apnea syndrome is a constellation of symptoms resulting from recurrent episodes of apnea during sleep. Often the upper airway becomes obstructed during slumber in this disorder. Symptoms relate to sleep deprivation and include morning headaches, daytime somnolence, personality changes with deteriorating intellectual capacity, nocturnal enuresis, and sexual dysfunction. diagnosis is assisted by polysomnographic recordings. Therapy is directed at the cause of obstruction when one can be found, weight loss in massively obese patients, tracheostomy in the symptomatic patient. Four patients with documented sleep apnea syndrome are discussed. One patient, a thin adolescent female underwent adenoidectomy without improvement. Two massively obese adult males required tracheostomy with marked amelioration of symptoms. One additional adult male was found to have sleep apnea due to severe, acquired micrognathia; he was significantly improved by tracheostomy. All three adult patients were found by endoscopic visualization to have marked pharyngeal soft tissue collapse with inspiration during apneic episodes. Possible causes of pharyngeal collapse are discussed. ( info) |
7/23. Sleeping beauty: a case of pickwickian syndrome. The patient arriving at the emergency department with somnolence must be evaluated quickly, efficiently, and with a definite goal in mind. head and neck trauma should always be suspected and protective steps taken in the unconscious patient. The coma mnemonic, AEIOU TIPS, (alcohol, epilepsy, insulin, overdose, uremia, trauma, infection, psychiatric, stroke) provides an excellent memory tool for the evaluation of decreased level of consciousness in the emergency setting. Interventions that provide diagnostic and therapeutic results (naloxone and 50% dextrose) should be initiated immediately while blood samples are drawn for pretreatment documentation. Each of the possible causes of lethargy or somnolence needs to be evaluated with the understanding that a multitude of factors may be present in the patient whose condition precludes a thorough history; the depressed diabetic may have taken an overdose of medications in addition to his insulin. Social preconceptions may also effect the outcome. The intoxicated patient described herein was allowed to "sleep it off" in the emergency department under the watchful eyes (and ears) of a nursing staff who faithfully recorded vital signs and pupil reactivity as the patient's blood gas values deteriorated. ( info) |
8/23. Optic disc edema in a pickwickian man mimicking hypertensive crisis. A 31-year-old obese man with essential hypertension developed progressive optic disc edema despite mild-to-moderate elevations of his blood pressure. Neurologic evaluation, including cranial axial tomography, nuclear magnetic resonance scan, and lumbar puncture, was unremarkable. Further evaluation revealed that the patient had sleep apnea syndrome. In contrast to the few patients reported with this syndrome, he had normal cerebrospinal fluid pressures and hypertension. The possible interplay of sleep apnea and hypertension in the development of optic disc edema is considered. ( info) |
9/23. Sleep apnea syndrome. Practical diagnostic method. We report a method of evaluating sleep apnea by equipment available and easily assembled in the majority of community hospitals. Two cases fully studied by this method are presented. ( info) |
10/23. Fetal response to periodic sleep apnea: a new syndrome in obstetrics. Periodic sleep apnea, a chronic sleep deprivation state, in which marked changes in the arterial PO2 and PCO2 tensions have been recorded, is a relatively new syndrome not previously reported in pregnancy. It is characterized by episodes of apnea, prevalently obstructive, during sleep. The majority of patients with this syndrome have snored heavily for years, suggesting a causal relationship between snoring and periodic sleep apnea. The effects of prolonged snoring on alveolar ventilation and systemic pressure(s) suggest that this snoring has physiopathological implications on maternal cardio-respiratory reserve and indirectly upon the fetus, especially as there are recordable changes in fetal heart rate and also a change in the acid-base status of the fetus. The possibility that this syndrome may have an adverse effect upon the fetus is stressed. ( info) |