Treatment and prognosis 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; "pickwickian syndrome") exists when an obese individual (body mass index [BMI] >30kg/m2) has awake alveolar hypoventilation (arterial carbon dioxide tension [PaCO2] >45 mmHg), which cannot be attributed to other conditions (eg, neuromuscular disease). Untreated OHS is a progressive disorder that is associated with significant morbidity such that prompt recognition and treatment is critical.
The treatment and prognosis of OHS are reviewed here. The clinical manifestations, diagnosis, complications, and pathogenesis of OHS are discussed separately. (See "Clinical manifestations and diagnosis of obesity hypoventilation syndrome" and "Epidemiology and pathogenesis of obesity hypoventilation syndrome".)
FIRST LINE THERAPY
Noninvasive positive airway pressure (PAP) together with weight loss are the initial first line therapies for patients with OHS. A comprehensive and multidisciplinary approach utilizing experts in obesity, sleep, and pulmonary medicine is recommended.
Positive airway pressure — All patients with OHS have some form of sleep disordered breathing, typically obstructive sleep apnea (OSA; 90 percent) or sleep-related hypoventilation (10 percent), warranting treatment with noninvasive PAP. PAP therapy should not be delayed while the patient tries to lose weight. Selection of the appropriate mode of PAP (eg, continuous PAP [CPAP], bilevel PAP [BPAP], volume cycled or hybrid modes of noninvasive ventilation)  and approach to initiating PAP therapy in patients with OHS are described in detail separately. (See "Noninvasive positive airway pressure therapy of the obesity hypoventilation syndrome".)
Obesity hypoventilation plus obstructive sleep apnea (continuous positive airway pressure) — CPAP is the typical mode chosen for treatment for OHS plus OSA, while BPAP, usually in the spontaneous–timed mode, is indicated in those who fail CPAP. (See "Noninvasive positive airway pressure therapy of the obesity hypoventilation syndrome", section on 'Obesity hypoventilation and obstructive sleep apnea'.)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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- FIRST LINE THERAPY
- Positive airway pressure
- - Obesity hypoventilation plus obstructive sleep apnea (continuous positive airway pressure)
- - Obesity hypoventilation plus sleep-related hypoventilation (bilevel positive airway pressure)
- Weight loss
- - Lifestyle modifications
- SECOND LINE THERAPY
- Treatments targeted at obesity hypoventilation and sleep disordered breathing
- - Tracheostomy
- Additional treatments targeted at weight loss
- - Bariatric surgery
- - Medication
- THERAPIES OF LIMITED VALUE OR ASSOCIATED WITH HARM
- Oxygen alone
- Respiratory stimulants
- SUPPORTIVE THERAPIES
- Avoidance of alcohol and sedatives
- Treatment of comorbid conditions
- SUMMARY AND RECOMMENDATIONS