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Erschienen in: Current Sleep Medicine Reports 4/2015

01.12.2015 | Sleep Related Breathing Disorders (T Lee-Chiong, Section Editor)

Obesity Hypoventilation Syndrome

verfasst von: Lee K. Brown

Erschienen in: Current Sleep Medicine Reports | Ausgabe 4/2015

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Abstract

As the prevalence of obesity continues to rise, morbidity associated with obesity becomes more and more endemic. Of particular interest to pulmonary and sleep medicine physicians is the entity of obesity hypoventilation syndrome (OHS), formerly known as Pickwickian syndrome. Most patients with OHS also will be found to present with obstructive sleep apnea (OSA), which appears to play a major role in the pathogenesis of OHS. With or without OSA, the etiology of OHS may also be related to the extreme mechanical limitations imposed by obesity on the ventilatory apparatus. Treatment of OHS has been profoundly changed by the advent of non-invasive positive pressure therapies, including continuous positive airway pressure, bilevel positive airway pressure, and average volume-assured pressure support. Despite these advances, morbidity and mortality remain elevated in these individuals unless substantial weight loss can be achieved.
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Zurück zum Zitat Bernhardt V, Lorenzo S, Babb TG, Zavorsky GS. Corrected end-tidal PCO2 accurately estimates PaCO2 at rest and during exercise in morbidly obese adults. Chest. 2013;143:471–7. Since most OHS patient are typically evaluated in outpatient sleep disorders centers without the ability to obtain arterial blood gas measurements, end-tidal pCO 2 may provide a viable screening tool to identify such individuals and guide appropriate testing and management. Bernhardt V, Lorenzo S, Babb TG, Zavorsky GS. Corrected end-tidal PCO2 accurately estimates PaCO2 at rest and during exercise in morbidly obese adults. Chest. 2013;143:471–7. Since most OHS patient are typically evaluated in outpatient sleep disorders centers without the ability to obtain arterial blood gas measurements, end-tidal pCO 2 may provide a viable screening tool to identify such individuals and guide appropriate testing and management.
75.
Zurück zum Zitat Liu SY, Lee TS, Bongard F. Accuracy of capnography in nonintubated surgical patients. Chest. 1992;102:1512–5.CrossRefPubMed Liu SY, Lee TS, Bongard F. Accuracy of capnography in nonintubated surgical patients. Chest. 1992;102:1512–5.CrossRefPubMed
76.•
Zurück zum Zitat 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(1):e000022. doi:10.1136/bmjresp-2014-000022. Another study that identifies a means to screen morbidly obese patients for OHS in outpatient sleep disorders centers that typically lack the ability to obtain arterial blood gas measurements. In this analysis of 245 morbidly obese patients, awake pulse oximetry and FVC had moderate success in identifying individuals with OHS.PubMedCentralCrossRefPubMed 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(1):e000022. doi:10.​1136/​bmjresp-2014-000022. Another study that identifies a means to screen morbidly obese patients for OHS in outpatient sleep disorders centers that typically lack the ability to obtain arterial blood gas measurements. In this analysis of 245 morbidly obese patients, awake pulse oximetry and FVC had moderate success in identifying individuals with OHS.PubMedCentralCrossRefPubMed
77.
Zurück zum Zitat Mokhlesi B, Tulaimat A, Faibussowitsch I, Wang Y, Evans AT. Obesity hypoventilation syndrome: prevalence and predictors in patients with obstructive sleep apnea. Sleep Breath. 2007;11:117–24.CrossRefPubMed Mokhlesi B, Tulaimat A, Faibussowitsch I, Wang Y, Evans AT. Obesity hypoventilation syndrome: prevalence and predictors in patients with obstructive sleep apnea. Sleep Breath. 2007;11:117–24.CrossRefPubMed
78.
Zurück zum Zitat Trakada GP, Steiropoulos P, Nena E, Constandinidis TC, Bouros D. Prevalence and clinical characteristics of obesity hypoventilation syndrome among individuals reporting sleep-related breathing symptoms in northern Greece. Sleep Breath. 2010;14:381–6.CrossRefPubMed Trakada GP, Steiropoulos P, Nena E, Constandinidis TC, Bouros D. Prevalence and clinical characteristics of obesity hypoventilation syndrome among individuals reporting sleep-related breathing symptoms in northern Greece. Sleep Breath. 2010;14:381–6.CrossRefPubMed
79.••
Zurück zum Zitat Manuel ARG, Hart N, Stradling JR. Is a raised bicarbonate, without hypercapnia, part of the physiologic spectrum of obesity-related hypoventilation? Chest. 2015;147:362–8. Elevated base excess may be helpful in identifying patients who are at risk of developing OHS and afford the opportunity to intervene earlier in the course of the disease.CrossRefPubMed Manuel ARG, Hart N, Stradling JR. Is a raised bicarbonate, without hypercapnia, part of the physiologic spectrum of obesity-related hypoventilation? Chest. 2015;147:362–8. Elevated base excess may be helpful in identifying patients who are at risk of developing OHS and afford the opportunity to intervene earlier in the course of the disease.CrossRefPubMed
80.
Zurück zum Zitat 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;128:177–81.CrossRefPubMed 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;128:177–81.CrossRefPubMed
81.••
Zurück zum Zitat Ojeda Castillejo E, de Lucas RP, Martin SL. Noninvasive mechanical ventilation in patients with obesity hypoventilation syndrome. Long-term outcome and prognostic factors. Arch Bronconeumol. 2015;51(2):61–8. One of the few studies in the OHS literature that separately examined patients with and without OSA. Subjects without OSA had higher PaCO 2 and were more frequently hospitalized. The groups did not differ with respect to overall mortality, which was, as would be expected, high in view of the degree of obesity. At 8 years (the approximate length of the overall follow-up), survival was only 60%. Lower FVC predicted lower survival in both groups. Ojeda Castillejo E, de Lucas RP, Martin SL. Noninvasive mechanical ventilation in patients with obesity hypoventilation syndrome. Long-term outcome and prognostic factors. Arch Bronconeumol. 2015;51(2):61–8. One of the few studies in the OHS literature that separately examined patients with and without OSA. Subjects without OSA had higher PaCO 2 and were more frequently hospitalized. The groups did not differ with respect to overall mortality, which was, as would be expected, high in view of the degree of obesity. At 8 years (the approximate length of the overall follow-up), survival was only 60%. Lower FVC predicted lower survival in both groups.
82.••
Zurück zum Zitat Piper A. Obesity hypoventilation syndrome: weighing in on therapy options. Chest. 2015. doi:10.1378/chest.15-0681. Comprehensive, state-of-the-art review of current thinking on best-practice treatment of OHS.PubMed Piper A. Obesity hypoventilation syndrome: weighing in on therapy options. Chest. 2015. doi:10.​1378/​chest.​15-0681. Comprehensive, state-of-the-art review of current thinking on best-practice treatment of OHS.PubMed
83.••
Zurück zum Zitat Masa JF, Corral J, Alonso ML. Efficacy and different treatment alternatives for obesity hypoventilation syndrome: Pickwick study. Am J Respir Crit Care Med. 2015;192:86–95. An impressive multicenter RCT comparing AVAPS, CPAP, and lifestyle modification (control group) using daytime PaCO 2 as the primary outcome measure plus several important secondary outcome variables. Both AVAPS and CPAP were more effective in improving PaCO 2 in comparison to lifestyle modification, and there was no significant difference between the active treatments. Of the secondary outcome measures, 6-minute walk distance, health related quality of life, and spirometric variables were better with AVAPS treatment compared to CPAP. Masa JF, Corral J, Alonso ML. Efficacy and different treatment alternatives for obesity hypoventilation syndrome: Pickwick study. Am J Respir Crit Care Med. 2015;192:86–95. An impressive multicenter RCT comparing AVAPS, CPAP, and lifestyle modification (control group) using daytime PaCO 2 as the primary outcome measure plus several important secondary outcome variables. Both AVAPS and CPAP were more effective in improving PaCO 2 in comparison to lifestyle modification, and there was no significant difference between the active treatments. Of the secondary outcome measures, 6-minute walk distance, health related quality of life, and spirometric variables were better with AVAPS treatment compared to CPAP.
84.•
Zurück zum Zitat Borel JC, Tamisier R, Gonzalez-Bermejo, et al. Noninvasive ventilation in mild obesity hypoventilation syndrome: a randomized controlled trial. Chest. 2012;141:692–702. These investigators compared CPAP therapy to lifestyle modification (as the control treatment) in patients with milder degrees of OHS. They reported significant improvements in PaCO 2 in the CPAP group that were not attained in the lifestyle improvement cohort. Borel JC, Tamisier R, Gonzalez-Bermejo, et al. Noninvasive ventilation in mild obesity hypoventilation syndrome: a randomized controlled trial. Chest. 2012;141:692–702. These investigators compared CPAP therapy to lifestyle modification (as the control treatment) in patients with milder degrees of OHS. They reported significant improvements in PaCO 2 in the CPAP group that were not attained in the lifestyle improvement cohort.
85.
Zurück zum Zitat Piper AJ, Wang D, Yee BJ, Barnes DJ, Grunstein RR. Randomised trial of CPAP vs bilevel support in the treatment of obesity hypoventilation syndrome without severe nocturnal desaturation. Thorax. 2008;63:395–401.CrossRefPubMed Piper AJ, Wang D, Yee BJ, Barnes DJ, Grunstein RR. Randomised trial of CPAP vs bilevel support in the treatment of obesity hypoventilation syndrome without severe nocturnal desaturation. Thorax. 2008;63:395–401.CrossRefPubMed
86.
Zurück zum Zitat Howard M, Piper A, Stevens B, et al. A randomised controlled trial of CPAP versus non-invasive ventilation for initial treatment of obesity hypoventilation syndrome. Eur Respir J. 2014;44 Suppl 58:4868. Howard M, Piper A, Stevens B, et al. A randomised controlled trial of CPAP versus non-invasive ventilation for initial treatment of obesity hypoventilation syndrome. Eur Respir J. 2014;44 Suppl 58:4868.
87.••
Zurück zum Zitat 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;67:727–34. A two-center RCT in which treatment with bilevel PAP-S/T was compared to AVAP in patients with morbid obesity and OHS. No between-group differences were found for PaCO 2 improvement, daytime sleepiness, health related quality of life, or sleep quality assess by actigraphy. 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;67:727–34. A two-center RCT in which treatment with bilevel PAP-S/T was compared to AVAP in patients with morbid obesity and OHS. No between-group differences were found for PaCO 2 improvement, daytime sleepiness, health related quality of life, or sleep quality assess by actigraphy.
88.
Zurück zum Zitat 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;103:165–72.CrossRefPubMed 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;103:165–72.CrossRefPubMed
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Zurück zum Zitat Storre JH, Seuthe B, Fiechter R, et al. Average volume-assured pressure support in obesity hypoventilation: a randomized crossover trial. Chest. 2006;130:815–21.CrossRefPubMed Storre JH, Seuthe B, Fiechter R, et al. Average volume-assured pressure support in obesity hypoventilation: a randomized crossover trial. Chest. 2006;130:815–21.CrossRefPubMed
90.•
Zurück zum Zitat Contal O, Adler D, Borel JC, et al. Impact of different back-up respiratory rates on the efficacy of non-invasive positive pressure ventilation in obesity hypoventilation syndrome: a randomized trial. Chest. 2013;143:37–46. This RCT pitted bilevel PAP-S against bilevel PAP-S/T employing either a low backup rate or a high backup rate in patients with OHS. Outcomes were assessed during single nights of polysomnography on each modality. Transcutaneous pCO 2 was similar for all 3 treatments. Bilevel PAP-S/T using either backup rate strategy was superior to spontaneous mode bilevel in terms of better resolution of respiratory events and fewer oxyhemoglobin desaturations. Bilevel PAP-S/T with the low backup rate was perceived by the patients as allowing better sleep quality and fewer arousals. Contal O, Adler D, Borel JC, et al. Impact of different back-up respiratory rates on the efficacy of non-invasive positive pressure ventilation in obesity hypoventilation syndrome: a randomized trial. Chest. 2013;143:37–46. This RCT pitted bilevel PAP-S against bilevel PAP-S/T employing either a low backup rate or a high backup rate in patients with OHS. Outcomes were assessed during single nights of polysomnography on each modality. Transcutaneous pCO 2 was similar for all 3 treatments. Bilevel PAP-S/T using either backup rate strategy was superior to spontaneous mode bilevel in terms of better resolution of respiratory events and fewer oxyhemoglobin desaturations. Bilevel PAP-S/T with the low backup rate was perceived by the patients as allowing better sleep quality and fewer arousals.
91.
Zurück zum Zitat Fletcher EC, Shah A, Qian W, Miller 3rd CC. “Near miss” death in obstructive sleep apnea: a critical care syndrome. Crit Care Med. 1991;19:1158–64.CrossRefPubMed Fletcher EC, Shah A, Qian W, Miller 3rd CC. “Near miss” death in obstructive sleep apnea: a critical care syndrome. Crit Care Med. 1991;19:1158–64.CrossRefPubMed
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Zurück zum Zitat Marik PE, Desai H. Characteristics of patients with the “malignant obesity hypoventilation syndrome” admitted to an ICU. J Intensive Care Med. 2013;28:124–30.CrossRefPubMed Marik PE, Desai H. Characteristics of patients with the “malignant obesity hypoventilation syndrome” admitted to an ICU. J Intensive Care Med. 2013;28:124–30.CrossRefPubMed
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Zurück zum Zitat De Cesare A, Cangemi B, Fiori E, Bononi M, Cangemi R, Basso L. Early and long-term clinical outcomes of bilio-intestinal diversion in morbidly obese patients. Surg Today. 2014;44:1424–33.CrossRefPubMed De Cesare A, Cangemi B, Fiori E, Bononi M, Cangemi R, Basso L. Early and long-term clinical outcomes of bilio-intestinal diversion in morbidly obese patients. Surg Today. 2014;44:1424–33.CrossRefPubMed
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Zurück zum Zitat Lumachi F, Marzano B, Fanti G, Basso SM, Mazza F, Chiara GB. Hypoxemia and hypoventilation syndrome improvement after laparoscopic bariatric surgery in patients with morbid obesity. In Vivo. 2010;24:329–31.PubMed Lumachi F, Marzano B, Fanti G, Basso SM, Mazza F, Chiara GB. Hypoxemia and hypoventilation syndrome improvement after laparoscopic bariatric surgery in patients with morbid obesity. In Vivo. 2010;24:329–31.PubMed
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Zurück zum Zitat McKenzie R, Wadhwa RK. Progesterone for the Pickwickian syndrome: respiratory implications: a case report. Anesth Analg. 1977;56:133–5.CrossRefPubMed McKenzie R, Wadhwa RK. Progesterone for the Pickwickian syndrome: respiratory implications: a case report. Anesth Analg. 1977;56:133–5.CrossRefPubMed
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Zurück zum Zitat Raurich JM, Rialp G, Ibáñez J, Llompart-Pou JA, Ayestarán I. Hypercapnic respiratory failure in obesity-hypoventilation syndrome: CO2 response and acetazolamide treatment effects. Respir Care. 2010;55:1442–8.PubMed Raurich JM, Rialp G, Ibáñez J, Llompart-Pou JA, Ayestarán I. Hypercapnic respiratory failure in obesity-hypoventilation syndrome: CO2 response and acetazolamide treatment effects. Respir Care. 2010;55:1442–8.PubMed
103.••
Zurück zum Zitat Castro-Anon O, Perez de Llano LA, De la Fuente Sanchez S, et al. Obesity-hypoventilation syndrome: increased risk of death over sleep apnea syndrome. PLoS One. 2015;10(2):e0117808. doi:10.1371/journal.pone.0117808. Retrospective analysis of 330 patients with OHS (most also had OSA) or OSA alone demonstrating a two-fold increase in mortality for the patients with OHS.PubMedCentralCrossRefPubMed Castro-Anon O, Perez de Llano LA, De la Fuente Sanchez S, et al. Obesity-hypoventilation syndrome: increased risk of death over sleep apnea syndrome. PLoS One. 2015;10(2):e0117808. doi:10.​1371/​journal.​pone.​0117808. Retrospective analysis of 330 patients with OHS (most also had OSA) or OSA alone demonstrating a two-fold increase in mortality for the patients with OHS.PubMedCentralCrossRefPubMed
104.•
Zurück zum Zitat Jennum P, Ibsen R, Kjellberg J. Morbidity prior to a diagnosis of sleep-disordered breathing: a controlled national study. J Clin Sleep Med. 2013;9:103–8. The authors analyzed data from the Danish National Patient Registry (1998–2006) to extract causes of morbidity in patients with OSA and OHS during the 3 years prior to their diagnosis. There were 755 OHS patients matched to 3020 controls. Of note, diabetes (and diabetic retinopathy), heart failure, hypertension, COPD, and asthma were more common in patients with OHS. The odds ratios for diabetes, hypertension, heart failure, COPD with acute exacerbation, and COPD were 4.16, 5.61, 5.02, 3.07, and 2.53, respectively.PubMedCentralPubMed Jennum P, Ibsen R, Kjellberg J. Morbidity prior to a diagnosis of sleep-disordered breathing: a controlled national study. J Clin Sleep Med. 2013;9:103–8. The authors analyzed data from the Danish National Patient Registry (1998–2006) to extract causes of morbidity in patients with OSA and OHS during the 3 years prior to their diagnosis. There were 755 OHS patients matched to 3020 controls. Of note, diabetes (and diabetic retinopathy), heart failure, hypertension, COPD, and asthma were more common in patients with OHS. The odds ratios for diabetes, hypertension, heart failure, COPD with acute exacerbation, and COPD were 4.16, 5.61, 5.02, 3.07, and 2.53, respectively.PubMedCentralPubMed
105.
Zurück zum Zitat Kauppert CA, Dvorak I, Kollert F, et al. Pulmonary hypertension in obesity-hypoventilation syndrome. Respir Med. 2013;107:2061–70.CrossRefPubMed Kauppert CA, Dvorak I, Kollert F, et al. Pulmonary hypertension in obesity-hypoventilation syndrome. Respir Med. 2013;107:2061–70.CrossRefPubMed
Metadaten
Titel
Obesity Hypoventilation Syndrome
verfasst von
Lee K. Brown
Publikationsdatum
01.12.2015
Verlag
Springer International Publishing
Erschienen in
Current Sleep Medicine Reports / Ausgabe 4/2015
Elektronische ISSN: 2198-6401
DOI
https://doi.org/10.1007/s40675-015-0026-8

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