Semin Respir Crit Care Med 2009; 30(3): 253-261
DOI: 10.1055/s-0029-1222439
© Thieme Medical Publishers

Obesity Hypoventilation Syndrome

Kenneth I. Berger1 , Roberta M. Goldring1 , David M. Rapoport1
  • 1Division of Pulmonary and Critical Care Medicine, Department of Medicine, New York University School of Medicine, NYU/Bellevue Medical Center, New York, New York
Further Information

Publication History

Publication Date:
18 May 2009 (online)

ABSTRACT

The term obesity hypoventilation syndrome (OHS) refers to the combination of obesity and chronic hypercapnia that cannot be directly attributed to underlying cardiorespiratory disease. Despite a plethora of potential pathophysiological mechanisms for gas exchange and respiratory control abnormalities that have been described in the obese, the etiology of hypercapnia in OHS has been only partially elucidated. Of particular note, obesity and coincident hypercapnia are often associated with some form of sleep disordered breathing (apnea/hypopnea or sustained periods of hypoventilation). From a conceptual point of view, even transient reductions of ventilation from individual sleep disordered breathing events must produce acute hypercapnia during the period of low ventilation. What is less clear, however, is the link between these transient episodes of acute hypercapnia and the development of chronic sustained hypercapnia persisting into wakefulness. A unifying view of how this comes about is presented in the following review. In brief, our concept is that chronic sustained hypercapnia (as in obesity hypoventilation) occurs when the disorder of ventilation that produces acute hypercapnia interacts with inadequate compensation (both during sleep and during the periods of wakefulness); neither alone is sufficient to fully explain the final result. The following discussion will amplify on both the potential reasons for acute hypercapnia in the obese and on what is known about the failure of compensation that must occur in these subjects.

REFERENCES

  • 1 Sin D D, Sutherland E R. Obesity and the lung, IV: Obesity and asthma.  Thorax. 2008;  63 1018-1023
  • 2 Laaban J P, Chailleux E, Laaban J P, Chailleux E. Daytime hypercapnia in adult patients with obstructive sleep apnea syndrome in France, before initiating nocturnal nasal continuous positive airway pressure therapy.  , [see comment] Chest. 2005;  127 710-715
  • 3 Mokhlesi B, Tulaimat A. Recent advances in obesity hypoventilation syndrome.  Chest. 2007;  132 1322-1336
  • 4 Sleep-related breathing disorders in adults: recommendations for syndrome definition and measurement techniques in clinical research. The Report of an American Academy of Sleep Medicine Task Force.  Sleep. 1999;  22 667-689
  • 5 Lee W Y, Mokhlesi B. Diagnosis and management of obesity hypoventilation syndrome in the ICU.  Crit Care Clin. 2008;  24 533-549, vii
  • 6 Rapoport D M, Garay S M, Epstein H, Goldring R M. Hypercapnia in the obstructive sleep apnea syndrome; a reevaluation of the “Pickwickian syndrome”.  Chest. 1986;  89 627-635
  • 7 Sullivan C E, Berthon-Jones M, Issa F G. Remission of severe obesity-hypoventilation syndrome after short-term treatment during sleep with nasal continuous positive airway pressure.  Am Rev Respir Dis. 1983;  128 177-181
  • 8 Berger K I, Ayappa I, Chatr-Amontri B et al.. Obesity hypoventilation syndrome as a spectrum of respiratory disturbances during sleep.  Chest. 2001;  120 1231-1238
  • 9 Javaheri S, Colangelo G, Lacey W, Gartside P S. Chronic hypercapnia in obstructive sleep apnea-hypopnea syndrome.  Sleep. 1994;  17 416-423
  • 10 Auchincloss H J, Cook E, Renzetti A D. Clinical and physiological aspects of a case of obesity, polycythemia, and alveolar hypoventilation.  J Clin Invest. 1955;  35 1537-1545
  • 11 Burwell C S, Robin E D, Whaley R D, Bickelmann A G. Extreme obesity associated with alveolar hypoventilation; a Pickwickian syndrome.  Am J Med. 1956;  21 811-818
  • 12 Gastaut H, Tassinari C A, Duron B. Polygraphic study of the episodic diurnal and nocturnal (hypnic and respiratory) manifestations of the Pickwick syndrome.  Brain Res. 1966;  1 167-186
  • 13 Guilleminault C, Eldridge F L, Dement W C. Insomnia with sleep apnea: a new syndrome.  Science. 1973;  181 856-858
  • 14 Lugaresi E, Coccagna G, Petrella A, Berti Ceroni G, Pazzaglia P. The disorder of sleep and respiration in the Pickwick syndrome [in Italian].  Sist Nerv. 1968;  20 38-50
  • 15 Dickens C. The Posthumous Papers of the Pickwick Club. London, UK; Chapman and Hall 1837
  • 16 Akashiba T, Akahoshi T, Kawahara S et al.. Clinical characteristics of obesity-hypoventilation syndrome in Japan: a multi-center study.  Intern Med. 2006;  45 1121-1125
  • 17 Mokhlesi B, Tulaimat A, Faibussowitsch I, Wang Y, Evans A T. Obesity hypoventilation syndrome: prevalence and predictors in patients with obstructive sleep apnea.  Sleep Breath. 2007;  11 117-124
  • 18 Kessler R, Chaouat A, Schinkewitch P et al.. The obesity-hypoventilation syndrome revisited: a prospective study of 34 consecutive cases.  Chest. 2001;  120 369-376
  • 19 Pérez de Llano L A, Golpe R, Ortiz Piquer M et al.. Short-term and long-term effects of nasal intermittent positive pressure ventilation in patients with obesity-hypoventilation syndrome.  Chest. 2005;  128 587-594
  • 20 Chouri-Pontarollo N, Borel J C, Tamisier R, Wuyam B, Levy P, Pépin J L. Impaired objective daytime vigilance in obesity-hypoventilation syndrome: impact of noninvasive ventilation.  Chest. 2007;  131 148-155
  • 21 Olson A L, Zwillich C. The obesity hypoventilation syndrome.  Am J Med. 2005;  118 948-956
  • 22 Anthony M. The obesity hypoventilation syndrome.  Respir Care. 2008;  53 1723-1730
  • 23 Ayappa I, Berger K I, Norman R G, Oppenheimer B W, Rapoport D M, Goldring R M. Hypercapnia and ventilatory periodicity in obstructive sleep apnea syndrome.  Am J Respir Crit Care Med. 2002;  166 1112-1115
  • 24 Resta O, Foschino Barbaro M P, Bonfitto P et al.. Hypercapnia in obstructive sleep apnoea syndrome.  Neth J Med. 2000;  56 215-222
  • 25 Resta O, Foschino-Barbaro M P, Bonfitto P et al.. Prevalence and mechanisms of diurnal hypercapnia in a sample of morbidly obese subjects with obstructive sleep apnoea.  Respir Med. 2000;  94 240-246
  • 26 Garay S M, Rapoport D, Sorkin B, Epstein H, Feinberg I, Goldring R M. Regulation of ventilation in the obstructive sleep apnea syndrome.  Am Rev Respir Dis. 1981;  124 451-457
  • 27 Jones R L, Nzekwu M M. The effects of body mass index on lung volumes.  Chest. 2006;  130 827-833
  • 28 Leech J, Onal E, Aronson R, Lopata M. Voluntary hyperventilation in obesity hypoventilation.  Chest. 1991;  100 1334-1338
  • 29 Piper A J, Grunstein R R. Current perspectives on the obesity hypoventilation syndrome.  Curr Opin Pulm Med. 2007;  13 490-496
  • 30 Rochester D F, Enson Y. Current concepts in the pathogenesis of the obesity-hypoventilation syndrome: mechanical and circulatory factors.  Am J Med. 1974;  57 402-420
  • 31 Lopata M, Onal E. Mass loading, sleep apnea, and the pathogenesis of obesity hypoventilation.  Am Rev Respir Dis. 1982;  126 640-645
  • 32 Sharp J T, Henry J P, Sweany S K, Meadows W R, Pietras R J. The total work of breathing in normal and obese men.  J Clin Invest. 1964;  43 728-739
  • 33 Kress J P, Pohlman A S, Alverdy J, Hall J B. The impact of morbid obesity on oxygen cost of breathing (VO(2RESP)) at rest.  Am J Respir Crit Care Med. 1999;  160 883-886
  • 34 Kaltman A J, Goldring R M. Role of circulatory congestion in the cardiorespiratory failure of obesity.  Am J Med. 1976;  60 645-653
  • 35 Bradley T D, Rutherford R, Lue F et al.. Role of diffuse airway obstruction in the hypercapnia of obstructive sleep apnea.  Am Rev Respir Dis. 1986;  134 920-924
  • 36 Tankersley C, Kleeberger S, Russ B, Schwartz A, Smith P. Modified control of breathing in genetically obese (ob/ob) mice.  J Appl Physiol. 1996;  81 716-723
  • 37 Barceló A, Barbé F, Llompart E et al.. Neuropeptide Y and leptin in patients with obstructive sleep apnea syndrome: role of obesity.  Am J Respir Crit Care Med. 2005;  171 183-187
  • 38 Berger K I, Ayappa I, Sorkin I B, Norman R G, Rapoport D M, Goldring R M. CO(2) homeostasis during periodic breathing in obstructive sleep apnea.  J Appl Physiol. 2000;  88 257-264
  • 39 Rapoport D M, Norman R G, Goldring R M. CO2 homeostasis during periodic breathing: predictions from a computer model.  J Appl Physiol. 1993;  75 2302-2309
  • 40 Berger K I, Ayappa I, Sorkin I B, Norman R G, Rapoport D M, Goldring R M. Postevent ventilation as a function of CO(2) load during respiratory events in obstructive sleep apnea.  J Appl Physiol. 2002;  93 917-924
  • 41 Greenberg H E, Rapoport D M, Rothenberg S A, Kanengiser L A, Norman R G, Goldring R M. Endogenous opiates modulate the postapnea ventilatory response in the obstructive sleep apnea syndrome.  Am Rev Respir Dis. 1991;  143 1282-1287
  • 42 Gislason T, Almqvist M, Boman G, Lindholm C E, Terenius L. Increased CSF opioid activity in sleep apnea syndrome: regression after successful treatment.  Chest. 1989;  96 250-254
  • 43 Berthon-Jones M, Sullivan C E. Ventilatory and arousal responses to hypoxia in sleeping humans.  Am Rev Respir Dis. 1982;  125 632-639
  • 44 Horner R L, Sanford L D, Pack A I, Morrison A R. Activation of a distinct arousal state immediately after spontaneous awakening from sleep.  Brain Res. 1997;  778 127-134
  • 45 Heinemann H O, Goldring R M. Bicarbonate and the regulation of ventilation.  Am J Med. 1974;  57 361-370
  • 46 Goldring R M, Turino G M, Heinemann H O. Respiratory-renal adjustments in chronic hypercapnia in man: extracellular bicarbonate concentration and the regulation of ventilation.  Am J Med. 1971;  51 772-784
  • 47 Tenney S M. Respiratory control in chronic pulmonary emphysema: a compromise adaptation.  J Maine Med Assoc. 1957;  48 375-379
  • 48 Norman R G, Goldring R M, Clain J M et al.. Transition from acute to chronic hypercapnia in patients with periodic breathing: predictions from a computer model.  J Appl Physiol. 2006;  100 1733-1741
  • 49 Berger K I, Ayappa I, Sorkin I B, Norman R G, Rapoport D M, Goldring R M. Post-apnea ventilation as a function of CO2 load during apnea [abstract].  Am J Respir Crit Care Med. 2000;  161 A712

Kenneth I BergerM.D. 

NYU School of Medicine, Rm. RR 108, 550 First Ave.

New York, NY 10016

Email: kenneth.berger@nyumc.org

    >