Obesity hypoventilation syndrome is defined as the presence of obesity (BMI > 30kg/m2) together with hypoventilation and daytime hypercapnia (PaCO2 > 45mmHg) in the absence of other causes. The pathogenesis involves mechanical, endocrine, and functional disturbances, while excessive fatigue and sleepiness are the most common symptoms. The diagnosis is made by a full body workup and polysomnography, and treatment includes a multidisciplinary approach.
Because patients with OHS have persistent hypercapnia and hypoxia, frequent sleepiness, drowsiness, fatigue, and difficulty performing regular activities are common symptoms in these patients. Sleep disturbances, including loud snoring and morning headaches, are frequently described, and sleep apnea is present in the majority of cases . Patients who develop complications such as pulmonary hypertension, or heart failure may present with dyspnea or edema of the extremities. All of these symptoms significantly impair the quality of life, and appropriate investigations should be made to establish the cause of such symptoms.
Once the suspicion toward OHS is made, a full diagnostic workup should be initiated. Primarily, laboratory tests, including CBC, which will likely show erythrocytosis, while bicarbonate levels in the blood are always increased. Hypothyroidism should be excluded as a potential cause of hypoventilation, and thyroid hormone levels should be measured. Noninvasive pulse oximetry reveals decreased oxygen saturation, and arterial blood gasses should be measured, which will reveal increased PCO2 and decreased PO2.
Under such circumstances, spirometry, chest X-ray, and possibly CT scan should be performed to assess the respiratory system, and exclude other causes of hypoventilation and hypercapnia. Spirometry may reveal restrictive lung disease, and reduced inspiratory and expiratory pressures, as well as reduced expiratory reserve volume. Echocardiography and chest X-ray may reveal right heart enlargement.
Polysomnography should be performed in all patients with suspicion for sleep apnea and involves overnight evaluation of PCO2 concentrations during nighttime . It is used as a definite diagnostic procedure in OHS.
Once all other potential causes of hypercapnia and respiratory failure have been excluded, and the presence of sleep-disordered breathing is confirmed in an obese individual, the diagnosis of Obesity hypoventilation syndrome can be confirmed, and appropriate therapeutic measures can be taken.
Treating OHS requires several steps, and involves multiple principles :
In addition to treatment of OHS via one or more of the strategies mentioned above, proper management of accompanying comorbidities, such as cardiovascular disease including heart failure, should be conducted, since significant morbidity and mortality is associated with other accompanying illnesses.
The prognosis depends on the severity of the disease at the time of diagnosis, the severity of obesity, presence of comorbidities, and adequate response to therapy. It is estimated that the majority of patients are undiagnosed until their 50s and 60s, which significantly impedes therapeutic principles to be effective . However, the outcome is good for patients who are treated with aggressive ventilatory therapy, but respiratory failure, the presence of concomitant heart disease and pulmonary hypertension are the significant predictors for poor outcomes despite adequate treatment .
It is not completely understood why this syndrome occurs and which factors determine its onset among the obese. It is assumed that the respiratory system is burdened by the increased body weight, which necessitates an increased workload . Eventually, chronically increased effort leads to respiratory complications and the inability of the lungs to perform gas exchange and supply the tissues with enough oxygen, with persistent hypercapnia and hypoventilation. Other factors, such as leptin resistance, and chronic elevation of inflammatory cytokines have been implicated in the development of this disease. Predisposing respiratory conditions, such as chronic obstructive pulmonary disease (COPD), or interstitial lung disease, have also been determined to have a potential role in these patients.
The actual number of obese individuals with OHS is not known, and the majority of epidemiological data is focused on obstructive sleep apnea . Results have been obtained in certain studies and indicate that the prevalence of OHS is between 10 and 38% in different groups , while other studies have reported that among hospitalized patients with a BMI > 35 kg/m2, more than 30% have OHS. Based on these data, it is estimated that the overall prevalence of OHS in the United States and other parts of the world is about 0.3% . It is determined that the greater the severity of obesity, the more increased the risk is of developing OHS.
Obesity hyperventilation syndrome is thought to involve multiple factors in its pathogenesis model. In addition to the increased effort of the lungs that is induced by mechanical obstruction of increased body weight, several other processes are thought to be involved:
Since this disease exclusively occurs in obese individuals, proper management of body weight through appropriate diet and exercise is vital in reducing the chances of developing this syndrome. It is increasingly evident that more individuals are becoming obese throughout the world, but good dietary habits and regular physical activity are essential to reducing the burden of this disease, but also many other that appear in obese individuals.
Obesity hypoventilation syndrome (OHS) is a distinct clinical entity and is one of the many complications that may develop in obese patients. It is defined as the presence of hypercapnia during daytime (PaCO2 > 45 mmHg) and hypoventilation that has no other known causes in exclusively obese individuals (BMI > 30kg/m2) . It is classified in the group of sleep disturbance disorders (SDBs), and it commonly occurs together with obstructive sleep apnea (OSA). The exact cause of this syndrome is unknown, but presumably involves several factors, including increased respiratory effort as a result of mechanical obstruction due to obesity; resistance to leptin (a hormone secreted by the adipose tissue to suppress appetite), which commonly develops in obese individuals, and contributes to hypoventilation, since leptin is additionally involved in maintaining normal respiration; and chronic elevation of inflammatory cytokines, including various members of the interleukin family and C-reactive protein (CRP), which presumably lead to chronic hypothalamic suppression and insulin resistance, all implicated in sleep-disordered breathing. Sleep apnea is diagnosed in the vast majority of patients with OHS. This disorder can carry a good prognosis if diagnosed and treated early, since the majority of symptoms, as well as disturbances in CO2/O2 content, are shown to be reversible. However, significant mortality rates are observed without appropriate therapy, because numerous complications may arise, including chronic states of hypoxemia, pulmonary hypertension and heart failure. Preexisting comorbidities play a role in patient outcomes as well. This syndrome is most commonly diagnosed in middle-aged males, and symptoms include frequent sleepiness, fatigue, poor daily performance, and in some cases, neurocognitive deficits. Snoring, morning headaches, and poor sleeping are commonly observed, as hypoventilation occurs during sleep as well and interferes with almost all sleep stages, more commonly with REM sleep . If accompanying diseases, such as heart failure or pulmonary hypertension are present, swelling of the extremities, dyspnea, and profound weakness is observed. The diagnosis is made by a full blood workup, including complete blood count (CBC), blood levels of bicarbonate, and arterial blood gas analysis to confirm hypercapnia. The extensive diagnostic panel should be conducted in these patients, to exclude other causes of hypoventilation and hypercapnia, including thyroid hormone levels and neuromuscular diseases, and a definite diagnosis is made by polysomnography. Before initiating treatment, other accompanying illnesses should be assessed, including pulmonary hypertension, heart failure, and other metabolic and endocrine complication that may arise in obesity. Treatment depends on the severity of disease, and may include supplementary oxygen, tracheostomy, and assisted ventilation techniques that aid in restoring normal blood gas levels and reduce the burden on the respiratory system. Proper management of accompanying comorbidities can be challenging, and treatment of OHS may depend on the presence of various diseases. However, their management is vital in ensuring a good outcome in such patients, in addition to treating OHS.
Obesity hypoventilation syndrome (OHS) is a condition seen in obese individuals in which the lungs are not able to perform their normal function, resulting in accumulation of bicarbonate and lower levels of oxygen in the blood. This disease occurs because individuals cannot maintain proper breathing rate, which leads to decreased expiration of carbon dioxide while reducing the inspiration of oxygen. It is not completely understood why this syndrome occurs, and why some obese individuals develop it, and some not, but it is implied that the burden of the respiratory system is increased as a result of the mechanical pressure of increased weight and fat content. Additional factors have been implicated in the development of this disease, but perhaps the most notable finding is that the majority of patients have concomitant obstructive sleep apnea.
Patients who have this condition experience frequent fatigue, as they are not able to sleep properly, as well as daytime sleepiness or drowsiness, and frequent morning headaches. Individuals are significantly limited in performing their daily activities, and some patients may develop progressive heart disease and respiratory failure, in which case difficulty breathing and swelling of the extremities may be observed. Because most of the symptoms can be reversed and almost completely managed with therapy, prompt identification and treatment are essential in maintaining the quality of life. It is important to note that several comorbidities may arise in the setting of obesity, such as diabetes mellitus, cardiovascular disease, and many other, and they may play a significant role in the outcome of patients with OHS.
The diagnosis of this syndrome is achieved by performing several laboratory tests. Measurement of oxygen and carbon dioxide concentrations in the blood are performed, and assessment of the heart and lungs is performed as well. To confirm the diagnosis, studies that evaluate blood gas concentrations and activity of the chest wall during sleep will be performed.
Treatment comprises several principles. Weight loss is essential in reducing the burden of the respiratory system, while assisted ventilation by introducing air under pressure into the lungs is the method of choice, but also aiding in the forceful expiration of carbon dioxide, thus promoting normal gas exchange. Other treatment principles include supplementary oxygen, medications, and in severe cases, surgery and tracheostomy.
The prognosis is good for patients in whom this diagnosis is made early, and in whom proper therapy is initiated and maintained. Various factors may play a role in the outcome of patients, such as the presence of comorbidities and the severity of the disease at the time of diagnosis, which is why an early diagnosis is vital in reducing the mortality rates.