Obesity Hypoventilation Syndrome

1. Obesity Hypoventilation Syndrome
ADE WIJAYA, MD
JULY 2018

2. Outline:
• Introduction
• Definition
• Epidemiology
• Pathophysiology
• Clinical features and diagnosis
• Management
• Summary

3. Introduction
• Obesity prevalence keep increasing
• Metabolic, cardiovascular and respiratory complications
• Respiratory complications: sleep apnea & obesity hypoventilation syndrome
• Pickwickian syndrome
Mokhlesi, B., Tulaimat, A., & Faibussowitsch, I. (2017). Obesity-hypoventilation syndrome. Principles and practice of sleep medicine, 6th ed. Elsevier, 1189-1199.
Egea-Santaolalla, C., & Javaheri, S. (2016). Obesity hypoventilation syndrome. Current Sleep Medicine Reports, 2(1), 12-19.

4. Definition
Obesity
(BMI>40 kg/m2)
SDB
(90 % OSA)
hypercapnia &
hypoxemia
PaCO2 > 45 mm Hg
PaO2 < 70 mm Hg
at sea level
Absent alternative causes
Olson AL, Zwillich C. The obesity hypoventilation syndrome. Am J Med. 2005;118(9):948–56.
Mokhlesi B, Kryger MH, Grunstein RR. Assessment and management of patients with obesity hypoventilation syndrome. Proc Am Thorac Soc. 2008;5(2):218–25.
Mokhlesi B, Tulaimat A. Recent advances in obesity hypoventilation syndrome. Chest.2007;132(4):1322–36.

5. Epidemiology
• Prevalence in general population: 0,15 – 0,3 %
• Prevalence in obese population: 19 - 31 %
• Prevalence in population with OSA: 9 - 20 %
Egea-Santaolalla, C., & Javaheri, S. (2016). Obesity hypoventilation syndrome. Current Sleep Medicine Reports, 2(1), 12-19.

6. Pathophysiology
• Respiratory mechanics
• Central respiratory drive
• Sleep disordered breathing
• Leptin resistance
Egea-Santaolalla, C., & Javaheri, S. (2016). Obesity hypoventilation syndrome. Current Sleep Medicine Reports, 2(1), 12-19.

7. Respiratory mechanics
Mokhlesi, B., Tulaimat, A., & Faibussowitsch, I. (2017). Obesity-hypoventilation syndrome. Principles and practice of sleep medicine, 6th ed. Elsevier, 1189-1199.

8. Central Respiratory Drive
OBESE WITHOUT OHS:
Higher rate of oxygen consumption and CO2 production  increase respiratory drive
In OHS
Higher rate of oxygen consumption and CO2 production  increase respiratory drive
due to blunted neural response
Egea-Santaolalla, C., & Javaheri, S. (2016). Obesity hypoventilation syndrome. Current Sleep Medicine Reports, 2(1), 12-19.

9. SDB & Leptin Resistance
• 90 % OSA
• others: sleep hypoventilation
Mokhlesi, B., Tulaimat, A., & Faibussowitsch, I. (2017). Obesity-hypoventilation syndrome. Principles and practice of sleep medicine, 6th ed. Elsevier, 1189-1199.
Egea-Santaolalla, C., & Javaheri, S. (2016). Obesity hypoventilation syndrome. Current Sleep Medicine Reports, 2(1), 12-19.

10. Clinical Features and Diagnosis
• Diagnosis of exclusion
• Often misdiagnosed
• 5th – 6th decade
Olson AL, Zwillich C. The obesity hypoventilation syndrome. Am J Med. 2005;118(9):948–56.
Mokhlesi B, Kryger MH, Grunstein RR. Assessment and management of patients with obesity hypoventilation syndrome. Proc Am Thorac Soc. 2008;5(2):218–25.
Mokhlesi B, Tulaimat A. Recent advances in obesity hypoventilation syndrome. Chest.2007;132(4):1322–36.
Berg G, et al. The use of health-care resources in obesity-hypoventilation syndrome. Chest.2001;120(2):377–83.

11. Management
• If left untreated: high rate mortality, decrease QOL, numerous comorbidities
• Comorbidities: Pulmonary hypertension, right cardiac insufficiency, angina and insulin
resistance
• Therefore, early diagnosis and treatment are mandatory
Fletcher EC, Shah A, Qian W, Miller 3rd CC. “Near miss” death in obstructive sleep apnea: a critical care syndrome. Crit Care Med. 50.
Nowbar S, Burkart KM, Gonzales R, et al. Obesity-associated hypoventilation in hospitalized patients: prevalence, effects, and outcome. Am J Med. 2004;116:1.
Miller A, Granada M. In-hospital mortality in the Pickwickian syndrome. Am J Med. 1974;56:144.

12. Management
Treatment goals:
- Normalization of the arterial carbon dioxide pressure during wakefulness and sleep
- Prevention of oxyhemoglobin desaturation during wakefulness and sleep
- Reversal of erythrocytosis, cor pulmonale and relief of the hypersomnia
MULTIDISCIPLINARY
APPROACH
Mokhlesi, B., Tulaimat, A., & Faibussowitsch, I. (2017). Obesity-hypoventilation syndrome. Principles and practice of sleep medicine, 6th ed. Elsevier, 1189-1199.

13. Management
• Positive Airway Pressure Therapy
• Weight loss
• Pharmacological therapy  Leptin therapy
• Tracheostomy
• Nocturnal supplemental oxygen (along with PAP)
• Exercise and Rehabilitation
Mokhlesi, B., Tulaimat, A., & Faibussowitsch, I. (2017). Obesity-hypoventilation syndrome. Principles and practice of sleep medicine, 6th ed. Elsevier, 1189-1199.
Egea-Santaolalla, C., & Javaheri, S. (2016). Obesity hypoventilation syndrome. Current Sleep Medicine Reports, 2(1), 12-19.

14. Summary
• Increasing prevalence
• Under- and misdiagnosed
• Significantly related to QOL and morbidities
• Early diagnosis and treatment
• Multidisciplinary approach