Noninvasive positive pressure therapy of the obesity hypoventilation syndrome
- Thomas J Martin, MD
Thomas J Martin, MD
- Associate Professor of Clinical Medicine
- University of Virginia School of Medicine
- Assistant Professor of Medicine
- Edward Via Virginia College of Osteopathic Medicine
- Associate Professor of Medicine
- Virginia Tech-Carilion School of Medicine
Obesity hypoventilation syndrome (OHS) is diagnosed in obese (body mass index [BMI] >30 kg/m2) patients when awake alveolar hypoventilation (PaCO2 >45 mmHg) cannot be attributed to pulmonary parenchymal disease, skeletal restriction, neuromuscular weakness, or pleural pathology . Most patients with OHS present with the signs or symptoms of chronic hypoventilation, although some may develop acute cardiopulmonary compromise that can be fatal if untreated. Application of positive airway pressure is the mainstay of therapy, regardless of the presentation or the presence or absence of sleep disordered breathing (eg, obstructive sleep apnea).
In this topic review, positive pressure therapy for patients with OHS is discussed. The pathogenesis, clinical manifestations, diagnosis, and treatment of OHS are discussed separately. (See "Clinical manifestations and diagnosis of obesity hypoventilation syndrome" and "Treatment of the obesity hypoventilation syndrome" and "Pathogenesis of obesity hypoventilation syndrome".)
MODES OF NONINVASIVE POSITIVE PRESSURE THERAPY
There are two major categories of noninvasive positive pressure therapy that are used to treat patients with obesity hypoventilation syndrome (OHS):
●Continuous positive airway pressure (CPAP)
●Noninvasive positive pressure ventilation (NPPV)
- Olson AL, Zwillich C. The obesity hypoventilation syndrome. Am J Med 2005; 118:948.
- Sullivan CE, Berthon-Jones M, Issa FG. Remission of severe obesity-hypoventilation syndrome after short-term treatment during sleep with nasal continuous positive airway pressure. Am Rev Respir Dis 1983; 128:177.
- Leech JA, Onal E, Lopata M. Nasal CPAP continues to improve sleep-disordered breathing and daytime oxygenation over long-term follow-up of occlusive sleep apnea syndrome. Chest 1992; 102:1651.
- Rapoport DM, Sorkin B, Garay SM, Goldring RM. Reversal of the "Pickwickian syndrome" by long-term use of nocturnal nasal-airway pressure. N Engl J Med 1982; 307:931.
- Berger KI, Ayappa I, Chatr-Amontri B, et al. Obesity hypoventilation syndrome as a spectrum of respiratory disturbances during sleep. Chest 2001; 120:1231.
- Kawata N, Tatsumi K, Terada J, et al. Daytime hypercapnia in obstructive sleep apnea syndrome. Chest 2007; 132:1832.
- Harada Y, Chihara Y, Azuma M, et al. Obesity hypoventilation syndrome in Japan and independent determinants of arterial carbon dioxide levels. Respirology 2014; 19:1233.
- Berthon-Jones M, Sullivan CE. Time course of change in ventilatory response to CO2 with long-term CPAP therapy for obstructive sleep apnea. Am Rev Respir Dis 1987; 135:144.
- Pérez de Llano LA, Golpe R, Piquer MO, et al. Clinical heterogeneity among patients with obesity hypoventilation syndrome: therapeutic implications. Respiration 2008; 75:34.
- Salord N, Mayos M, Miralda RM, et al. Continuous positive airway pressure in clinically stable patients with mild-to-moderate obesity hypoventilation syndrome and obstructive sleep apnoea. Respirology 2013; 18:1135.
- Banerjee D, Yee BJ, Piper AJ, et al. Obesity hypoventilation syndrome: hypoxemia during continuous positive airway pressure. Chest 2007; 131:1678.
- Piper AJ, Wang D, Yee BJ, et al. Randomised trial of CPAP vs bilevel support in the treatment of obesity hypoventilation syndrome without severe nocturnal desaturation. Thorax 2008; 63:395.
- Masa JF, Celli BR, Riesco JA, et al. The obesity hypoventilation syndrome can be treated with noninvasive mechanical ventilation. Chest 2001; 119:1102.
- Pérez de Llano LA, Golpe R, Ortiz Piquer M, et al. Short-term and long-term effects of nasal intermittent positive pressure ventilation in patients with obesity-hypoventilation syndrome. Chest 2005; 128:587.
- Chouri-Pontarollo N, Borel JC, Tamisier R, et al. Impaired objective daytime vigilance in obesity-hypoventilation syndrome: impact of noninvasive ventilation. Chest 2007; 131:148.
- Cuvelier A, Muir JF. Acute and chronic respiratory failure in patients with obesity-hypoventilation syndrome: a new challenge for noninvasive ventilation. Chest 2005; 128:483.
- Priou P, Hamel JF, Person C, et al. Long-term outcome of noninvasive positive pressure ventilation for obesity hypoventilation syndrome. Chest 2010; 138:84.
- Waldhorn RE. Nocturnal nasal intermittent positive pressure ventilation with bi-level positive airway pressure (BiPAP) in respiratory failure. Chest 1992; 101:516.
- Laursen SB, Dreijer B, Hemmingsen C, Jacobsen E. Bi-level positive airway pressure treatment of obstructive sleep apnoea syndrome. Respiration 1998; 65:114.
- Heinemann F, Budweiser S, Dobroschke J, Pfeifer M. Non-invasive positive pressure ventilation improves lung volumes in the obesity hypoventilation syndrome. Respir Med 2007; 101:1229.
- Borel JC, Tamisier R, Gonzalez-Bermejo J, et al. Noninvasive ventilation in mild obesity hypoventilation syndrome: a randomized controlled trial. Chest 2012; 141:692.
- Nowbar S, Burkart KM, Gonzales R, et al. Obesity-associated hypoventilation in hospitalized patients: prevalence, effects, and outcome. Am J Med 2004; 116:1.
- Redolfi S, Corda L, La Piana G, et al. Long-term non-invasive ventilation increases chemosensitivity and leptin in obesity-hypoventilation syndrome. Respir Med 2007; 101:1191.
- de Lucas-Ramos P, de Miguel-Díez J, Santacruz-Siminiani A, et al. Benefits at 1 year of nocturnal intermittent positive pressure ventilation in patients with obesity-hypoventi lation syndrome. Respir Med 2004; 98:961.
- Adler D, Perrig S, Takahashi H, et al. Polysomnography in stable COPD under non-invasive ventilation to reduce patient-ventilator asynchrony and morning breathlessness. Sleep Breath 2012; 16:1081.
- Fanfulla F, Taurino AE, Lupo ND, et al. Effect of sleep on patient/ventilator asynchrony in patients undergoing chronic non-invasive mechanical ventilation. Respir Med 2007; 101:1702.
- Contal O, Adler D, Borel JC, et al. Impact of different backup respiratory rates on the efficacy of noninvasive positive pressure ventilation in obesity hypoventilation syndrome: a randomized trial. Chest 2013; 143:37.
- Piper AJ, Sullivan CE. Effects of short-term NIPPV in the treatment of patients with severe obstructive sleep apnea and hypercapnia. Chest 1994; 105:434.
- Storre JH, Seuthe B, Fiechter R, et al. Average volume-assured pressure support in obesity hypoventilation: A randomized crossover trial. Chest 2006; 130:815.
- Janssens JP, Metzger M, Sforza E. Impact of volume targeting on efficacy of bi-level non-invasive ventilation and sleep in obesity-hypoventilation. Respir Med 2009; 103:165.
- Murphy PB, Davidson C, Hind MD, et al. Volume targeted versus pressure support non-invasive ventilation in patients with super obesity and chronic respiratory failure: a randomised controlled trial. Thorax 2012; 67:727.
- Masa JF, Corral J, Alonso ML, et al. Efficacy of Different Treatment Alternatives for Obesity Hypoventilation Syndrome. Pickwick Study. Am J Respir Crit Care Med 2015; 192:86.
- Carrillo A, Ferrer M, Gonzalez-Diaz G, et al. Noninvasive ventilation in acute hypercapnic respiratory failure caused by obesity hypoventilation syndrome and chronic obstructive pulmonary disease. Am J Respir Crit Care Med 2012; 186:1279.
- Lemyze M, Taufour P, Duhamel A, et al. Determinants of noninvasive ventilation success or failure in morbidly obese patients in acute respiratory failure. PLoS One 2014; 9:e97563.
- Berry RB, Chediak A, Brown LK, et al. Best clinical practices for the sleep center adjustment of noninvasive positive pressure ventilation (NPPV) in stable chronic alveolar hypoventilation syndromes. J Clin Sleep Med 2010; 6:491.
- Guo YF, Sforza E, Janssens JP. Respiratory patterns during sleep in obesity-hypoventilation patients treated with nocturnal pressure support: a preliminary report. Chest 2007; 131:1090.
- Storre JH, Steurer B, Kabitz HJ, et al. Transcutaneous PCO2 monitoring during initiation of noninvasive ventilation. Chest 2007; 132:1810.
- Mokhlesi B, Tulaimat A, Evans AT, et al. Impact of adherence with positive airway pressure therapy on hypercapnia in obstructive sleep apnea. J Clin Sleep Med 2006; 2:57.
- Masa JF, Celli BR, Riesco JA, et al. Noninvasive positive pressure ventilation and not oxygen may prevent overt ventilatory failure in patients with chest wall diseases. Chest 1997; 112:207.
- Hollier CA, Harmer AR, Maxwell LJ, et al. Moderate concentrations of supplemental oxygen worsen hypercapnia in obesity hypoventilation syndrome: a randomised crossover study. Thorax 2014; 69:346.
- Wijesinghe M, Williams M, Perrin K, et al. The effect of supplemental oxygen on hypercapnia in subjects with obesity-associated hypoventilation: a randomized, crossover, clinical study. Chest 2011; 139:1018.
- MODES OF NONINVASIVE POSITIVE PRESSURE THERAPY
- Continuous positive airway pressure
- Noninvasive positive pressure ventilation
- - Bilevel positive airway pressure
- - Volume cycled ventilation
- - Hybrid modes
- INITIATING NONINVASIVE POSITIVE PRESSURE THERAPY
- Acute decompensated OHS
- Chronic compensated OHS
- - Follow-up
- - Supplemental oxygen
- SUMMARY AND RECOMMENDATIONS