9-41: Obesity-Hypoventilation Syndrome (Pickwickian Syndrome)

In obesity-hypoventilation syndrome, awake alveolar hypoventilation appears to result from a combination of blunted ventilatory drive and increased mechanical load imposed upon the chest by obesity. Voluntary hyperventilation returns the PCO₂ and the PO₂ toward normal values, a correction not seen in lung diseases causing chronic respiratory failure, such as COPD. Diagnostic criteria include a body mass index greater than 30, an arterial partial pressure of carbon dioxide greater than 45 mm Hg, and exclusion of other causes of alveolar hypoventilation. Most patients with obesity-hypoventilation syndrome also suffer from obstructive sleep apnea, which must be treated aggressively if identified as a comorbid disorder. Therapy of obesity-hypoventilation syndrome consists mainly of weight loss, which improves hypercapnia and hypoxemia as well as the ventilatory responses to hypoxia and hypercapnia. Avoidance of sedative hypnotics, opioids, and alcohol is also recommended. NIPPV is helpful in many patients. Patients with obesity-hypoventilation syndrome have a higher risk of complications in the perioperative period, including respiratory failure, intubation, and cardiac failure. Recognition of these patients in the perioperative period is an important safety measure.