Noninvasive positive airway pressure therapy of the obesity hypoventilation syndrome
- Thomas J Martin, MD
Thomas J Martin, MD
- Associate Professor of Medicine
- Virginia Tech-Carilion School of Medicine
- Assistant Professor of Medicine
- Edward Via Virginia College of Osteopathic Medicine
- Associate Professor of Clinical Medicine
- University of Virginia School of Medicine
Obesity hypoventilation syndrome (OHS) is diagnosed in obese (body mass index [BMI] >30 kg/m2) patients when awake alveolar hypoventilation (partial pressure of arterial carbon dioxide >45 mmHg) cannot be attributed to other causes (eg, neuromuscular diseases) . Noninvasive positive airway pressure (PAP) is first-line treatment for patients with OHS, although the effect on survival is unclear.
In this topic review, PAP therapy for patients with OHS is discussed. The pathogenesis, clinical manifestations, diagnosis, and other treatments for OHS are discussed separately. (See "Clinical manifestations and diagnosis of obesity hypoventilation syndrome" and "Treatment and prognosis of the obesity hypoventilation syndrome" and "Epidemiology and pathogenesis of obesity hypoventilation syndrome".)
CHOOSING A MODE OF NONINVASIVE POSITIVE PRESSURE THERAPY
For patients with OHS, we recommend noninvasive positive airway pressure (PAP) therapy during sleep rather than lifestyle modifications alone in order to improve symptoms and parameters of awake ventilation (ie, arterial partial pressure of carbon dioxide [PaCO2]). This recommendation is based upon the rationale that OHS will progress if not treated with PAP and improvement is dependent upon optimal compliance with therapy. Mode selection for initial PAP therapy is determined by the presence or absence of comorbid obstructive sleep apnea (OSA) based on the results of in-laboratory polysomnography (PSG). (See "Clinical manifestations and diagnosis of obesity hypoventilation syndrome", section on 'Identify coexistent sleep disordered breathing'.):
●Approximately 90 percent of patients with OHS have coexisting obstructive sleep apnea (OSA), in which case continuous positive airway pressure (CPAP) is the initial mode of choice. (See 'Continuous positive airway pressure' below.)
●For patients with OHS and sleep-related hypoventilation (ie, few obstructive events during sleep), and patients with acutely decompensated OHS, bilevel positive airway pressure (BPAP) is usually the initial mode of choice. Patients with OHS and OSA who fail or do not tolerate CPAP are also treated with BPAP. For those who fail or do not tolerate BPAP, a hybrid mode (average volume-assured pressure support) or, less commonly, volume-cycled ventilation may be chosen. (See 'Bilevel positive airway pressure' below and 'Volume-cycled ventilation' below.)To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
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- CHOOSING A MODE OF NONINVASIVE POSITIVE PRESSURE THERAPY
- OBESITY HYPOVENTILATION AND OBSTRUCTIVE SLEEP APNEA
- Initial therapy
- - Continuous positive airway pressure
- Initial settings
- - Assessing treatment response
- Assess symptoms
- Assess indicators of alveolar hypoventilation
- Second line therapies
- - Bilevel positive airway pressure
- Initial settings
- Bilevel versus continuous positive airway pressure
- - Other noninvasive ventilation modes
- Average volume-assured pressure support
- Volume cycled positive pressure
- OBESITY HYPOVENTIALTION AND SLEEP-RELATED HYPOVENTILATION
- Bilevel positive airway pressure
- PATIENTS WITH ACUTE HYPERCAPNIC RESPIRATORY FAILURE AND OHS
- Bilevel positive airway ventilation
- Volume-cycled ventilation
- Invasive mechanical ventilation
- SUPPLEMENTAL OXYGEN DURING POSITIVE AIRWAY PRESSURE VENTILATION
- SUMMARY AND RECOMMENDATIONS