Clinical manifestations and diagnosis of obesity hypoventilation syndrome
- Amanda Piper, PhD
Amanda Piper, PhD
- Associate Professor
- Faculty of Medicine, University of Sydney
- Brendon Yee, MBChB, PhD
Brendon Yee, MBChB, PhD
- Associate Professor, University of Sydney
- Royal Prince Alfred Hospital Sydney, Woolcock Institute of Research
Obesity Hypoventilation Syndrome (OHS) is defined as the presence of awake alveolar hypoventilation in an obese individual which cannot be attributed to other conditions associated with alveolar hypoventilation [1-3]. OHS is associated with increased cardiovascular morbidity and mortality. Consequently, early detection and treatment are crucial to minimize these adverse effects.
The clinical manifestations, diagnosis, and complications of OHS are reviewed here, while the pathogenesis and treatment are discussed separately. (See "Epidemiology and pathogenesis of obesity hypoventilation syndrome" and "Treatment and prognosis of the obesity hypoventilation syndrome" and "Noninvasive positive airway pressure therapy of the obesity hypoventilation syndrome".)
The major risk factor for OHS is obesity (body mass index [BMI] >30 kg/m2), in particular, severe obesity (BMI >50 kg/m2), where prevalence may be as high as 50 percent. However, not all patients with obesity develop OHS.
Risk factors in obese patients are poorly defined but may include [4-6]:
●Significant increase in waist:hip ratio (ie, central obesity)
- Mokhlesi B. Obesity hypoventilation syndrome: a state-of-the-art review. Respir Care 2010; 55:1347.
- Randerath W, Verbraecken J, Andreas S, et al. Definition, discrimination, diagnosis and treatment of central breathing disturbances during sleep. Eur Respir J 2017; 49.
- Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research. The Report of an American Academy of Sleep Medicine Task Force. Sleep 1999; 22:667.
- Basoglu OK, Tasbakan MS. Comparison of clinical characteristics in patients with obesity hypoventilation syndrome and obese obstructive sleep apnea syndrome: a case-control study. Clin Respir J 2014; 8:167.
- Piper AJ, Grunstein RR. Obesity hypoventilation syndrome: mechanisms and management. Am J Respir Crit Care Med 2011; 183:292.
- Mokhlesi B, Kryger MH, Grunstein RR. Assessment and management of patients with obesity hypoventilation syndrome. Proc Am Thorac Soc 2008; 5:218.
- Castro-Añón O, Pérez de Llano LA, De la Fuente Sánchez S, et al. Obesity-hypoventilation syndrome: increased risk of death over sleep apnea syndrome. PLoS One 2015; 10:e0117808.
- 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.
- BaHammam AS. Prevalence, clinical characteristics, and predictors of obesity hypoventilation syndrome in a large sample of Saudi patients with obstructive sleep apnea. Saudi Med J 2015; 36:181.
- Olson AL, Zwillich C. The obesity hypoventilation syndrome. Am J Med 2005; 118:948.
- Nowbar S, Burkart KM, Gonzales R, et al. Obesity-associated hypoventilation in hospitalized patients: prevalence, effects, and outcome. Am J Med 2004; 116:1.
- Povitz M, James MT, Pendharkar SR, et al. Prevalence of Sleep-disordered Breathing in Obese Patients with Chronic Hypoxemia. A Cross-Sectional Study. Ann Am Thorac Soc 2015; 12:921.
- 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.
- Kessler R, Chaouat A, Schinkewitch P, et al. The obesity-hypoventilation syndrome revisited: a prospective study of 34 consecutive cases. Chest 2001; 120:369.
- 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.
- Borel JC, Burel B, Tamisier R, et al. Comorbidities and mortality in hypercapnic obese under domiciliary noninvasive ventilation. PLoS One 2013; 8:e52006.
- Priou P, Hamel JF, Person C, et al. Long-term outcome of noninvasive positive pressure ventilation for obesity hypoventilation syndrome. Chest 2010; 138:84.
- Palm A, Midgren B, Janson C, Lindberg E. Gender differences in patients starting long-term home mechanical ventilation due to obesity hypoventilation syndrome. Respir Med 2016; 110:73.
- Marik PE, Desai H. Characteristics of patients with the "malignant obesity hypoventilation syndrome" admitted to an ICU. J Intensive Care Med 2013; 28:124.
- Bingol Z, Pıhtılı A, Cagatay P, et al. Clinical predictors of obesity hypoventilation syndrome in obese subjects with obstructive sleep apnea. Respir Care 2015; 60:666.
- Mokhlesi B, Tulaimat A, Faibussowitsch I, et al. Obesity hypoventilation syndrome: prevalence and predictors in patients with obstructive sleep apnea. Sleep Breath 2007; 11:117.
- Macavei VM, Spurling KJ, Loft J, Makker HK. Diagnostic predictors of obesity-hypoventilation syndrome in patients suspected of having sleep disordered breathing. J Clin Sleep Med 2013; 9:879.
- Manuel AR, Hart N, Stradling JR. Is a raised bicarbonate, without hypercapnia, part of the physiologic spectrum of obesity-related hypoventilation? Chest 2015; 147:362.
- Hart N, Mandal S, Manuel A, et al. Obesity hypoventilation syndrome: does the current definition need revisiting? Thorax 2014; 69:83.
- Littleton SW. Impact of obesity on respiratory function. Respirology 2012; 17:43.
- Andersen J, Rasmussen JP, Eriksen J. Pulmonary function in obese patients scheduled for jejuno-ileostomy. Acta Anaesthesiol Scand 1977; 21:346.
- 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.
- Piper AJ. Obesity hypoventilation syndrome--the big and the breathless. Sleep Med Rev 2011; 15:79.
- Castro-Añón O, Golpe R, Pérez-de-Llano LA, et al. Haemodynamic effects of non-invasive ventilation in patients with obesity-hypoventilation syndrome. Respirology 2012; 17:1269.
- Kauppert CA, Dvorak I, Kollert F, et al. Pulmonary hypertension in obesity-hypoventilation syndrome. Respir Med 2013; 107:2061.
- Mandal S, Suh ES, Boleat E, et al. A cohort study to identify simple clinical tests for chronic respiratory failure in obese patients with sleep-disordered breathing. BMJ Open Respir Res 2014; 1:e000022.
- Hollier CA, Maxwell LJ, Harmer AR, et al. Validity of arterialised-venous P CO2, pH and bicarbonate in obesity hypoventilation syndrome. Respir Physiol Neurobiol 2013; 188:165.
- Budweiser S, Riedl SG, Jörres RA, et al. Mortality and prognostic factors in patients with obesity-hypoventilation syndrome undergoing noninvasive ventilation. J Intern Med 2007; 261:375.
- Martinez FJ, Bermudez-Gomez M, Celli BR. Hypothyroidism. A reversible cause of diaphragmatic dysfunction. Chest 1989; 96:1059.
- Ladenson PW, Goldenheim PD, Ridgway EC. Prediction and reversal of blunted ventilatory responsiveness in patients with hypothyroidism. Am J Med 1988; 84:877.
- MASSUMI RA, WINNACKER JL. SEVERE DEPRESSION OF THE RESPIRATORY CENTER IN MYXEDEMA. Am J Med 1964; 36:876.
- Skatrud J, Iber C, Ewart R, et al. Disordered breathing during sleep in hypothyroidism. Am Rev Respir Dis 1981; 124:325.
- Kessler R, Chaouat A, Weitzenblum E, et al. Pulmonary hypertension in the obstructive sleep apnoea syndrome: prevalence, causes and therapeutic consequences. Eur Respir J 1996; 9:787.
- Kaw R, Hernandez AV, Walker E, et al. Determinants of hypercapnia in obese patients with obstructive sleep apnea: a systematic review and metaanalysis of cohort studies. Chest 2009; 136:787.
- Banerjee D, Yee BJ, Piper AJ, et al. Obesity hypoventilation syndrome: hypoxemia during continuous positive airway pressure. Chest 2007; 131:1678.
- Resta O, Foschino-Barbaro MP, Bonfitto P, et al. Prevalence and mechanisms of diurnal hypercapnia in a sample of morbidly obese subjects with obstructive sleep apnoea. Respir Med 2000; 94:240.
- Jennum P, Ibsen R, Kjellberg J. Morbidity prior to a diagnosis of sleep-disordered breathing: a controlled national study. J Clin Sleep Med 2013; 9:103.
- Berg G, Delaive K, Manfreda J, et al. The use of health-care resources in obesity-hypoventilation syndrome. Chest 2001; 120:377.
- Borel JC, Roux-Lombard P, Tamisier R, et al. Endothelial dysfunction and specific inflammation in obesity hypoventilation syndrome. PLoS One 2009; 4:e6733.
- RISK FACTORS
- CLINICAL MANIFESTATIONS
- Symptoms and signs
- Laboratory tests
- Pulmonary function tests
- Imaging and cardiac studies
- DIAGNOSTIC APPROACH
- Suspecting obesity hypoventilation
- Indicators of chronic alveolar hypoventilation
- Exclude other causes of hypercapnia and alveolar hypoventilation
- IDENTIFY COEXISTENT SLEEP DISORDERED BREATHING
- DIFFERENTIAL DIAGNOSIS
- ASSESS COMPLICATIONS
- SUMMARY AND RECOMMENDATIONS