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Annual Congress of Malaysian Thoracic Society Symposium 3C Pneumonia PREVENTION STRATEGIES FOR COMMUNITY ACQUIRED PNEUMONIA Patrick Chan Malaysia Pneumonia is the leading cause of death in children below 5 years worldwide and remains a significant burden predominantly in low and middle income countries. Despite advances in management and standardised treatment programmes, high treatment failure and case fatality continue to occur in these countries. All children should be protected against pneumonia and through promoting a healthy environment and access to effective preventive and treatment measures. General strategies in preventing childhood pneumonia include improving nutritional status with supplementation, exclusive breastfeeding and adherence to personal and environmental hygiene. Specific strategies adopted in preventing childhood pneumonia are immunization and antibiotics prophylaxis. Standard immunizations against pertussis, Hib type B and measles have been shown to be effective in reducing both the burden of childhood pneumonia and its associated mortality. More recently, the introduction of a multivalent pneumococcal vaccine has been a remarkable addition to the prevention of childhood pneumonia. Antibiotic prophylaxis with isoniazid is recommended in the prevention of mycobacterial disease in both healthy and HIV afflicted contacts. Recognition of preventive strategies for childhood pneumonia is not adequate without a proper implementation programme. Improved access to these proven preventive strategies remains crucial in reducing the disease burden and mortality associated with childhood pneumonia. 31
Annual Congress of Malaysian Thoracic Society Symposium 4A Sleep Disorders Obesity Hypoventilation Syndrome – Managing this elusive condition Amanda Piper Australia Obesity hypoventilation syndrome (OHS) is a disorder characterized by awake hypercapnia (PaCO2>45mmHg), obesity (BMI>30kg/m2) and sleep disordered breathing in the absence of other disorders that could explain hypoventilation. While many will present with symptoms indistinguishable from eucapnic obstructive sleep apnea, individuals with OHS are more likely to be dyspneic, hypoxemic, and have lower limb oedema and cor pulmonale than similarly obese individuals without awake hypercapnia (1). Despite the significant clinical consequences of untreated OHS, a diagnosis is often overlooked resulting in a delay in commencing appropriate therapy (1,2). Oxygen therapy is frequently prescribed for those with awake hypoxia, especially during acute hospital presentations, but has the potential to hasten the development of severe hypercapnia and acidosis if used as sole therapy (3). Positive airway pressure therapy (CPAP or bilevel support) is considered first line treatment, but the actual mode used needs to be tailored to reverse the individual’s sleep disordered breathing. Upper airway obstruction is present in the majority of patients with OHS, with around 50-80% of individuals responding to CPAP therapy alone as initial therapy (4-6). In many countries, OHS is now the primary indication for home bilevel therapy, being used for those individuals who fail CPAP therapy because of persisting hypoventilation or in whom sleep hypoventilation in the absence of upper airway obstruction occurs (7). Adherence to PAP therapy is critical in improving awake gas exchange (6), with poor survival rates in non-compliant patients compared to those continuing therapy long term (8,9). However, awake hypercapnia may persist even in patients compliant with therapy (6). Longer term outcomes for these individuals compared to those fully responding to therapy in terms of quality of life, health resource use and survival have not been studied. Significant weight loss is an important long term goal to improve breathing and comorbidities related to obesity, and is associated with improved lung function, gas exchange and quality of life. Clinicians need to maintain a high level of suspicion regarding the possibility of hypoventilation in the morbidly obese patient, particularly in the presence of severely restricted spirometry, serum bicarbonate >27mEq/L or concurrent severe OSA (10). References (1) Berg et al, Chest 2001;120:377-83 (2) Nowbar et al, Am J Med 2004;116:1-7 (3) Wijesinghe et al, Chest 2011;139:1018-1024 (4) Piper et al, Thorax 2008: (5) Banerjee et al, Chest 2007;131:1678-84 (6) Mokhlesi et al, J Clin Sleep Med 2006;2:57-62 (7) Janssens et al, Chest 2003;123:67-79 (8) Perez de Llano et al, Chest 2005;128:587-94 (9) Priou et al, Chest 2010;138:84-90 (10) Mokhlesi et al, Sleep Breath 2007;11:117-24 32
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