30 mar. 2010

Problemas nocturnos debido a la obesidad



98 por ciento de las personas con obesidad mórbida presentan el síndrome. ESPECIAL
  • La apnea es el periodo de respiración interrumpida
Las personas con obesidad y sobrepeso también están expuestos a desarrollar el llamado Síndrome de Apnea Obstructiva del Sueño
CIUDAD DE MÉXICO.- Además de ser proclives a padecer diabetes, hipertensión, hipercolesterolemia (niveles altos de colesterol en sangre) o artrosis degenerativa (desgaste del cartílago y deformación de la superficie del hueso de una articulación), entre otras afecciones, las personas con obesidad y sobrepeso también están expuestos a desarrollar el llamado Síndrome de Apnea Obstructiva del Sueño (SAOS), que les evita disfrutar de un sueño reparador.

De acuerdo con cifras de la Federación Mexicana de Otorrinolaringología y Cirugía de Cabeza y Cuello A. C. (Fesormex), 98 por ciento de las personas con obesidad mórbida (personas cuyo índice de masa corporal es mayor a 40) presentan el síndrome de apnea obstructiva del sueño.

Según el doctor Jorge Parra Mariscal, miembro de dicho organismo, la apnea es el periodo de respiración interrumpida, de 10 a 30 segundos durante el sueño, que pueden llevar al paciente a situaciones extremas como infartos o accidentes vasculares.

Durante estos episodios, que pueden ocurrir hasta 400 veces durante la noche, la persona deja de oxigenarse correctamente, por lo que entran en acción mecanismos compensatorios de alerta como la hipertensión y la taquicardia. Lo cual, aclaró el especialista, están relacionados con el desarrollo de problemas de tipo vascular, neuronal o cardiaco.

Tras un bloqueo momentáneo del paso del aire, las respiraciones normales se reinician con un resoplido o un jadeo; razón por la cual aquellas personas con ese síndrome suelen roncar fuertemente. Sin embargo, el ronquido no siempre es indicio de apnea obstructiva.

Otros síntomas de esa enfermedad son: movimiento de las piernas durante el sueño, somnolencia diurna, dolor de cabeza, dificultad para levantarse en las mañanas, falta de concentración y memoria, baja de rendimiento en el trabajo, pérdida o disminución del interés sexual, garganta seca al despertar e hipertensión arterial; así como diaforesis o sudoraciones mientras duerme.

De acuerdo con Parra Mariscal, puede haber apneas centrales y periféricas. Las primeras son aquellas en las que el paciente presenta alguna afección neuronal y el cerebro suspende temporalmente el envío de señales a los músculos que controlan la respiración.

En tanto, el síndrome periférico se presenta cuando uno o más agentes externos obstruyen las vías aéreas. Cabe mencionar que se trata de un evento multifactorial; sin embargo, existen algunas causas comunes tales como: la desviación del tabique nasal, la presencia de amígdalas hipertróficas o aumentadas de tamaño, sufrir alguna alergia, ser fumador y tener sobrepeso.

A este respecto, aseguró que en el momento del sueño el cuerpo se encuentra totalmente relajado. Por lo que, “la flacidez de los tejidos producen una obstrucción natural; además de que la capacidad pulmonar se ve limitada por la obesidad o sobrepeso”.

Además, el exceso de grasa corporal cubre el tejido que rodea la garganta, lo que facilita la aparición o agravamiento del síndrome de apnea, al estrechar el paso de aire por esta zona.

Asimismo, el experto de la Fesormex señaló que las personas con exceso de peso también es proclive a padecer hernias hiatales (parte del estómago se introduce en el tórax por un agujero o hiato en el diafragma) y reflujo, que a su vez ocasiona faringitis. “Una cosa lleva a la otra y hay que ir armando el rompecabezas poco a poco”, refirió.

El diagnóstico del síndrome de apnea se hace a partir de una revisión que, de ser requerida incluye una endoscopia de fosas nasales, cavidad oral, laringe, faringe y cuello; con lo que el otorrinolaringólogo verifica la presencia de alguna obstrucción.

Asimismo, es necesario realizar una polisomnografía. Este estudio mide los ciclos y etapas del sueño a partir de las ondas cerebrales (EEG), la actividad eléctrica de los músculos, los movimientos oculares, la frecuencia respiratoria, la presión arterial, la saturación del oxígeno en la sangre y el ritmo cardíaco. Los resultados, señaló el especialista, reflejan los niveles de oxigenación, si el paciente está haciendo apenas, con qué frecuencia y de qué duración; además del tipo de obstrucción: central o periférica.

Parra Mariscal explicó que en la mayoría de los casos el síndrome de apnea es controlable. El tratamiento va en función de la historia clínica de cada paciente; sin embargo, es posible erradicar factores externos que se relacionan, entre los que figura el tabaquismo, la ingesta de alcohol antes de dormir, evitar consumir alimentos y acostarse inmediatamente.

En caso de tener alguna obstrucción en las vías respiratorias, dijo, ésta puede ser retirada quirúrgicamente; con ello se reducen las posibilidades de que la apnea continúe presentándose.

El miembro de la Fesormex destacó que aquellas personas que sufren de obesidad deben someterse a un tratamiento multidisciplinario para bajar de peso, controlar el síndrome de apnea y prevenir la aparición de otras enfermedades.

Con información de Agencia ID.
CRÉDITOS: Informador Redacción / LEER

http://www.informador.com.mx/tecnologia/2010/189925/6/problemas-nocturnos-debido-a-la-obesidad.htm


APPLAC Agradece al informador por su colaboración  y desarrollo de temas  acerca de la salud  Fanuel.


Nota.  Por eso es tan importante para las personas con Polio y con SPP mantener  un buen peso y evitar  dentro de lo que se pueda  subir de peso en exceso,  si su médico rehabilitador le ha  dado precisas indicaciones de hacer un tipo de ejercicio, no lo abandone , piense que es obtener calidad de vida y prevenir complicaciones respiratorias como lo es la Apnea. Fanuel.



Hacer un Amigo es una Gracia
Tener un amigo es un Don
Conservar un Amigo es una Virtud
Ser un Amigo es un Honor
 Liliana Marasco Garrido




















28 mar. 2010

Post-polio Syndrome Management requires careful assessment and a multidisciplinary approach.


Post-polio Syndrome

Post-polio syndrome (PPS) is the onset of new deterioration in function that may occur many years after recovery from acute poliomyelitis. PPS comprises various possible symptoms such as fatigue, weakness, joint and muscle pain, reduced respiratory function or dysphagia. PPS does not necessarily imply progressive deterioration, and can be helped by treatment. Management requires careful assessment and a multidisciplinary approach.
Definition/diagnosis
Suggested criteria for diagnosis of PPS are:1
  • Previous history of poliomyelitis.
  • Stable period after recovery (usually > 15 years).
  • New symptoms, such as generalised fatigue, new weakness, abnormal muscle fatigue and muscle atrophy.
  • Exclusion of other cause of muscle weakness (but note that problems can be multifactorial2, as discussed below).
Note:
  • There is no universal definition of PPS, but most sources use one similar to the above.
  • Some experts suggest that PPS may be diagnosed in those where there is no clear history of paralytic polio, but where the past history or investigations suggest that previous polio is likely.3
Aetiology2
There is NO reactivation of the polio virus infection (patients may need reassurance about this).

The exact cause of PPS is unknown:
  • There may be new muscle atrophy and weakness relating to changes in motorneurones.
  • Overuse or disuse of muscles play an important role.4
  • The cause of PPS symptoms may be multifactorial. For example, disabilities resulting from acute polio, combined with activities of daily living, can produce large stresses acting on abnormal muscles and joints. This may lead to other problems which contribute to PPS, such as:
    • Joint deformities
    • Osteoporosis
    • Scoliosis
    • Cervical spondylosis
    • Peripheral nerve entrapment (can occur with callipers, crutches etc.)
Epidemiology4
It is estimated that PPS may occur in 28-75% of patients with previous polio. The time interval is usually around 35 years, but may be 8-70 years after the acute polio episode.
Presentation
Common symptoms are:4
  • Generalised fatigue
  • Joint and muscle pain
  • New muscle or joint weakness
  • Muscle atrophy
  • Cold intolerance
  • Bulbar symptoms - speech, swallowing or respiratory symptoms
  • Worsening respiratory function - may present as headaches, fatigue or sleep disorder (see below under 'Respiratory and sleep problems in post-polio syndrome').
Any of these can lead to a deterioration in day-to-day functioning. A small change in clinical terms can mean a large one in its effects on daily living.
Assessment
  • Listen to the patient's story.
  • The most important question to ask is not "can you do this activity?", e.g. climbing stairs, but "howdo you do it?" This can reveal the functional change, e.g. stopping to rest half way, going upstairs by shifting on their bottom.5
  • A patient questionnaire such as "my polio life" can be useful.6
  • Multidisciplinary assessment may be needed, e.g. involving physiotherapist, occupational therapist, neurologist, orthopaedic/orthotic team and respiratory physician.
Bear in mind that various factors can make assessment more difficult:7
  • Polio survivors are used to coping and adapting. Hence the importance of asking - and observing -how patients carry out each activity.
  • Symptoms can vary from day to day and can be affected by recent activity, overuse or rest.
  • Patients may deliberately allow for a stressful hospital visit day by resting beforehand. This can give a falsely good picture. Ask what symptoms are like "on bad days".
  • Results can appear normal if patients are given long rests between tests, or if only the best result is recorded.
  • Respiratory and sleep problems are easily missed (see below under 'Respiratory and sleep problems in post-polio syndrome').
  • Anecdotally, patients with PPS have had their symptoms dismissed after apparently normal or near-normal results of tests, such as lung function or muscle power.

Investigations

These will depend on symptoms, but could include:
  • Muscle tests - but be aware that simple tests of isometric muscle strength may be insensitive5,8
  • Respiratory investigations (see below under 'Assessment of respiratory problems')
  • Sleep studies (see below under 'Assessment of respiratory problems')
  • Swallowing studies, e.g. barium swallow
  • Investigations to exclude other causes
Differential diagnosis1
Other causes of fatigue or weakness, e.g:
Other causes of pain, e.g:
Management2
A multidisciplinary approach is helpful.9 Some important aspects of management are:
  • The correct balance of rest and exercise is essential:4,10
    • Avoid overuse, as too much exercise causes increased weakness and fatigue in damaged muscles.
    • Graded exercise is beneficial - this should probably be broken up by periods of rest.
    • Non-swimming exercise in warm water often helps.
    • Many polio survivors are used to leading active lives and, to some extent, ignoring their disability. Adapting to PPS and the need for more rest may require lifestyle and employment changes.11
  • Orthopaedic and orthotic management of skeletal problems, e.g:
    • Simple supports for knee, ankle and cervical spine can improve function.
    • Replace damaged aids.
  • Muscle pain:
  • Anaesthesia requires special considerations.12
  • Nutrition:
    • Good nutrition and weight control.
    • Some patients find that a high protein diet is helpful (e.g. the post-polio institute "hypoglycaemia diet").11
  • Specific treatment of other problems, e.g. dysphagia and respiratory and sleep problems (see below under 'Respiratory and sleep problems in post-polio syndrome').
Respiratory and sleep problems in post-polio syndrome13,14,15

Importance

  • Respiratory problems in PPS are an important cause of symptoms and complications, including sleep disorders.
  • They may be under-diagnosed or inadequately assessed.
  • Treatment can improve both quality of life and prognosis.

Aetiology14

Respiratory problems in PPS may be due to one or more of:
  • Respiratory muscle weakness.
  • Bulbar impairment - this may affect control of the upper airway or the respiratory cycle. If the upper airway is affected, there may be obstructive sleep apnoea.
  • Skeletal deformity - scoliosis or chest wall stiffness.
  • Other pathology, e.g. COPD, asthma, obesity.
  • Aspiration - if swallowing affected.
All these are likely to worsen during sleep. The pattern of respiratory impairment may behypoventilation, obstructive sleep apnoea, or both.16

Symptoms

Respiratory failure can develop insidiously - symptoms may be subtle or unnoticed. Breathlessness may not be a symptom in patients with limited mobility. Possible symptoms are:
  • Sleep disruption, eventually leading to insomnia, daytime sleepiness or fatigue.
  • Morning headaches, irritability, poor concentration, anxiety or depression.
  • Abnormal sleep movements, nocturnal confusion, vivid dreams.
  • Breathlessness may be positional.
  • Weak cough, chest infections.

Signs

May be subtle - possible signs are:
  • Unexplained tachypnoea.
  • Use of accessory muscles.
  • Abdominal paradox - this is inward movement of the abdomen on inspiration while the upper chest expands.
    • May be best seen with patient supine during a sniff manoeuvre. When upright, can be missed as the diaphragm passively descends at the beginning of inspiration.
  • Severe, untreated nocturnal hypoxaemia can cause pulmonary hypertension, giving signs such as raised JVP and ankle oedema.

Assessment of respiratory problems

  • Listen to the patient's story and preferences.
  • Assess:
    • Voice and cough
    • Chest deformity
    • Observe patients in realistic situations, e.g. doing repeated tests or actions, and doing everyday actions in which they may be using the necessary breathing muscles to achieve another task
  • Investigations:
    • Peak flow and cough peak flow
    • Spirometry
      • Both seated AND supine spirometry are needed
      • A sensitive indicator of respiratory muscle weakness is reduction in maximal inspiratory pressure
    • Oximetry (and possibly capnography)
    • Sleep study (polysomnogram)
    • ECG and chest X-ray if appropriate
    Full sets of lung function tests and arterial blood gases may not be helpful in this scenario, unless intrinsic lung disease is suspected.

Management of respiratory problems

There are various options - choice will depend on the patient's individual situation and preferences.
Night-time mechanical ventilation is often used. This helps by resting the respiratory muscles at night, and preventing deterioration of respiratory function during sleep. It also treats the secondary sleep disorder.

Supportive measures include:
  • Not smoking
  • Avoiding sedatives and alcohol
  • Optimal weight and nutrition
  • Pneumococcal and influenza vaccination
  • Postural support if needed
  • Prompt treatment of chest infections
  • Techniques such as assisted cough or glossopharyngeal breathing ('frog breathing')
  • Chest expansion exercises
Assisted breathing options are:
  • Non-invasive intermittent positive pressure ventilation (NIV or NPPV) is often useful - see box below.
  • Rocking bed:
    • This helps breathing by rocking a patient consecutively head up and head down. It is surprisingly effective, especially where muscle weakness is mainly diaphragmatic
  • Pneumobelt:
    • This gives intermittent abdominal pressure ventilation and is useful for daytime assistance
  • Negative pressure ventilation:
    • Examples are tank ventilators (iron lung), jacket ventilators (Tunnicliffe), and cuirass ventilators. The devices are cumbersome, and mainly used where NIV is not tolerated, or to provide 'respite' from NIV
  • Tracheostomy ventilation.

Non-invasive ventilation and 'bi-levels' explained,13,14

NIV increases alveolar ventilation. It is provided by a portable ventilator and a tightly-fitting nasal or facial mask or nasal "pillow".
  • Note: NIV is NOT the same as continuous positive airway pressure (CPAP). CPAP is useful for obstructive sleep apnoea because it maintains the upper airway. It is not normally indicated for hypoventilation from respiratory muscle weakness.
People with neuromuscular disease may have difficulty breathing in, so require NIV with higher inspiratory than expiratory pressures. This can be provided using a 'bi-level' ventilator:
  • Bi-level ventilators developed by modifying CPAP. The inspiratory positive airway pressure (IPAP) and expiratory positive airway pressure (EPAP) settings are adjusted separately.
  • The difference between IPAP and EPAP is called the span.
  • For example, a patient may require an IPAP of 14 and an EPAP of 3.
  • Sensitive flow triggers enable normal breathing to be supported. There may be a back-up control to provide ventilation if respiratory effort fails to trigger a breath.
Prognosis
  • Experience suggests that the functional deterioration does not necessarily progress.
  • Fatigue and reduction in mobility may stabilise or progress very slowly.
Prevention
Prevention of acute polio infection is discussed elsewhere (see separate article on Poliomyelitis).

Prevention of PPS is not much discussed in the literature. Given the various known contributing factors, it seems possible that PPS problems might be reduced by:
  • Careful management of exercise and daily living activities to optimise muscle and joint use, and prevent overuse or disuse.
  • Correct maintenance of aids and prostheses.
  • Monitoring and early treatment of associated/contributing problems such as:
    • Osteoporosis.
    • Obesity.
    • Respiratory problems.

Document references
  1. Thorsteinsson G; Management of postpolio syndrome. Mayo Clin Proc. 1997 Jul;72(7):627-38.; [full text]
  2. Howard RS; Poliomyelitis and the postpolio syndrome. BMJ. 2005 Jun 4;330(7503):1314-8.
  3. Halstead LS, Silver JK; Nonparalytic polio and postpolio syndrome. Am J Phys Med Rehabil. 2000 Jan-Feb;79(1):13-8. [abstract]
  4. Khan F; Rehabilitation for postpolio sequelae. Aust Fam Physician. 2004 Aug;33(8):621-4. [abstract]
  5. Boone H. Problems experienced by polio survivors and suggested solutions. Presentation for occupational therapists, given at the Neurological Occupation Therapy Conference, October 2008. Information and slides kindly supplied by Hilary Boone (personal communication), Lincolnshire Post-Polio Network, UK.
  6. My Polio Life. A patient questionnaire providing baseline information and comparison charts, for use by polio survivors and their health professionals. Lincolnshire Post-Polio Network 2007.
  7. Boone H. When test results do not match important symptoms. Conference presentation, Post Polio Association of South Florida, Miami, 2007. Presentation slides kindly supplied by Hilary Boone (personal communication), Lincolnshire Post-Polio Network, UK.
  8. Hildegunn L, Jones K, Grenstad T, et al; Perceived disability, fatigue, pain and measured isometric muscle strength in patients with post-polio symptoms. Physiother Res Int. 2007 Mar;12(1):39-49. [abstract]
  9. Davidson AC, Auyeung V, Luff R, et al; Prolonged benefit in post-polio syndrome from comprehensive rehabilitation: a pilot study. Disabil Rehabil. 2009;31(4):309-17. [abstract]
  10. Agre JC; The role of exercise in the patient with post-polio syndrome. Ann N Y Acad Sci. 1995 May 25;753:321-34. [abstract]
  11. Polio Outreach of Washington. A registered charity providing information for polio survivors. Accessed June 2009.
  12. Lambert DA, Giannouli E, Schmidt BJ; Postpolio syndrome and anesthesia. Anesthesiology. 2005 Sep;103(3):638-44. [abstract]
  13. Howard RS, Davidson C; Long term ventilation in neurogenic respiratory failure. J Neurol Neurosurg Psychiatry. 2003 Sep;74 Suppl 3:iii24-30.
  14. Lincolnshire Post-Polio Information Newsletter. Volume 5, issue 9, June 2006. Issue covering respiratory problems.
  15. Bach JR, Tilton M. Pulmonary dysfunction and its management in post-polio patients. NeuroRehabilitation 1997;8:139-153. In Lincolnshire Post-Polio Library, copy by kind permission of Dr. Bach.
  16. Hsu AA, Staats BA; "Postpolio" sequelae and sleep-related disordered breathing. Mayo Clin Proc. 1998 Mar;73(3):216-24. [abstract]

Internet and further reading
Acknowledgements EMIS is grateful to Dr N Hartree for writing this article and to Dr Colin Tidy for earlier versions. The final copy has passed scrutiny by the independent Mentor GP reviewing team. ©EMIS 2009. Document ID: 2637 Document Version: 23 Document Reference: bgp2385 Last Updated: 8 Jul 2009 Planned Review: 8 Jul 2011

The authors and editors of this article are employed to create accurate and up to date content reflecting reliable research evidence, guidance and best clinical practice. They are free from anycommercial conflicts of interest. Find out more about updating.http://www.patient.co.uk/doctor/Post-Polio-Syndrome.htm





Hacer un Amigo es una Gracia
Tener un amigo es un Don
Conservar un Amigo es una Virtud
Ser un Amigo es un Honor

Polio Film

http://www.pbs.org/wgbh/americanexperience/films/polio/

video

Salk Institute

Polio Video

Polio Lungs

https://youtu.be/qytuMHXDlds

Twitter

Enlaces

México Post Polio Una Vida Un Camino Una Experiencia
http://postpoliosinmex.blogspot.com/

Post Polio LITAFF A.C.

www.postpoliolitaff.org/
Postpoliolitaff.- Asociación Post Polio Litaff A.C Primera Organización oficial sobre Síndrome de Post Poliomielitis En México.


Polio y Efectos Secundarios SPP
http://polioyspp.blogspot.com/
- See more at: http://polioamigossinfronteras.blogspot.mx/#sthash.6PkHAkfM.dpuf

APPLAC

Polio Reinders

March Of Dimes Polio History

Erradicación de La poliomielitis

Buscar este blog

No more Polio