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 the mainstay of therapy for patients with OHS.
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
Noninvasive positive airway pressure (PAP) therapy during sleep is first-line treatment for patients with OHS based upon the rationale that PAP improves indicators of alveolar ventilation and prevents further disease progression. The effect of PAP on survival is unclear, but appears to be improved as compared with historical controls. (See 'Efficacy' below and 'Efficacy' below.).
Patients should undergo in-laboratory polysomnography (PSG) to detect the associated form of sleep disordered breathing, guide mode selection for PAP therapy, and to determine optimal PAP and supplemental oxygen settings (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.)
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- CHOOSING A MODE OF NONINVASIVE POSITIVE PRESSURE THERAPY
- PATIENTS WITH OBESITY HYPOVENTILATION AND OBSTRUCTIVE SLEEP APNEA
- Continuous positive airway pressure
- - Initial settings
- - Efficacy
- PATIENTS WITH OHS AND OSA WHO FAIL CPAP
- Bilevel positive airway pressure
- - Initial settings
- - Efficacy
- PATIENTS WITH OHS AND SLEEP-RELATED HYPOVENTILATION
- Bilevel positive airway pressure
- PATIENTS WITH OHS WHO FAIL CPAP AND/OR BPAP
- Average volume-assured pressure support
- PATIENTS WITH ACUTE DECOMPENSATED OHS
- Bilevel positive airway ventilation
- Volume-cycled ventilation
- Invasive mechanical ventilation
- SUPPLEMENTAL OXYGEN DURING POSITIVE AIRWAY PRESSURE VENTILATION
- Assess symptoms
- Assess indicators of alveolar hypoventilation
- SUMMARY AND RECOMMENDATIONS