obstructive hypoventilation

cpap is considered the first-line treatment modality for ohs phenotype with concomitant severe obstructive sleep apnoea, whereas niv is preferred in the minority of ohs patients with hypoventilation during sleep with no or milder forms of obstructive sleep apnoea (approximately <30% of ohs patients). multiple studies have reported a prevalence of ohs between 8% and 20% in obese patients referred to sleep centres for evaluation of sleep disordered breathing [7–10]. of note, this may be an overestimate of ohs prevalence in countries with a lower prevalence of obesity compared to the usa. the identification of one predominant or a combination of these key mechanisms in a patient is crucial to characterise the ohs phenotype and to anticipate responses to the different modalities of positive airway pressure (pap) therapies [23]. rem sleep hypoventilation occurs in ohs owing to a combination of obesity-related mechanical constraints affecting the function of the diaphragm and reduced central respiratory drive. the prevalence of hypertension in patients with ohs is very high, ranging between 55% and 88% [2, 9, 19, 26, 31, 33, 35–42]. in a randomised controlled trial (rct) of 35 patients with mild ohs, 1 month of niv therapy led to a significant decrease of daytime paco2 and an improvement of sleep disordered breathing in contrast to the lifestyle modification as a control group [31].




in a secondary analysis of the pickwick project, in patients with ohs and concomitant severe osa, 2 months of niv therapy decreased systolic pulmonary artery pressure (especially in the group of patients with pulmonary hypertension at baseline) and left ventricular hypertrophy in contrast to the same period of therapy with lifestyle modification [46]. in the largest pickwick study [2], 2 months of cpap or niv treatment in patients with ohs and concomitant severe osa achieved similar improvements in daytime paco2, arterial bicarbonate, sleepiness and polysomnography measures. the notion that dynamic respiratory support with varying levels of pap for different stages of sleep or body position leads to better control of sleep disordered breathing in ohs is empirically appealing. therefore, it is pertinent to incorporate weight management strategies into the care of patients with ohs. the risk of surgery in patients with untreated ohs is high but once successfully established on pap therapy, these risks appear to be mitigated [90, 91]. the outcome of obese patients admitted to critical care is favourable and therefore a patient’s location of care should be carefully considered [98]. err articles are open access and distributed under the terms of the creative commons attribution non-commercial licence 4.0. note: we only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail.

this may be similar to the clinical scenario observed in patients with sleep-disordered breathing and neuromuscular disease (3). in this review, we highlight the pathophysiology that determines which patients with obesity develop awake hypoventilation and the clinical impact of ohs. this would contribute to greater reductions in lung volumes and more marked mechanical ventilatory constraints, which would increase the work of breathing while reducing respiratory muscle efficiency in patients with ohs. figure 1. outline of some of the interactions between factors believed to be contributing to the development of hypercapnia in patients with severe obesity. new data on possible ways of overcoming leptin resistance and emerging clinical trials suggest that in the future using recombinant leptin to reverse ohs may be possible (41).

the presence of high inflammatory markers before and after treatment for sleep-disordered breathing in ohs has also been shown to be a factor associated with poor prognosis in this population (51). improving quality of life is an important aspect of intervention in patients with chronic hypoventilation, including ohs, as there appears to be an association between health-related quality of life and mortality (54). longer-term data will be required to provide treatment algorithms that explain which patients can be initially managed with cpap from the outset or switched to this therapy after a period of bilevel ventilation. a reduction in nocturnal obstructive events and normalization of awake co2 can be achieved in some patients with severe ohs after undergoing a tracheostomy (65, 66). this will require better understanding of the epidemiology of ohs and particularly which patients with obesity and sleep-disordered breathing develop this condition over time. given the significant morbidity and mortality associated with untreated or poorly managed disease, more information is needed regarding barriers to using therapy and outcomes for patients in whom response to therapy is incomplete.

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