From the Guidelines
The most appropriate initial intervention for obesity hypoventilation syndrome (OHS) is treatment with positive airway pressure (PAP) during sleep, with the specific type of PAP therapy depending on the presence and severity of concomitant obstructive sleep apnea (OSA). For stable ambulatory patients diagnosed with OHS and concomitant severe OSA, CPAP therapy is suggested as the first-line treatment 1. However, for hospitalized patients with respiratory failure suspected of having OHS, NIV therapy is recommended before discharge from the hospital, until outpatient workup and titration of PAP therapy can be performed 1. Some key considerations for PAP therapy in OHS include:
- Initiating treatment with CPAP for patients with severe OSA (apnea-hypopnea index > 30 events/h) 1
- Using NIV for patients without severe OSA or in hospitalized patients with respiratory failure 1
- Titration of PAP therapy in a sleep laboratory to ensure optimal settings 1 In addition to PAP therapy, weight-loss interventions that produce sustained weight loss of 25-30% of actual body weight are suggested, as this level of weight loss is most likely required to achieve resolution of hypoventilation 1. Overall, the initial intervention for OHS should prioritize PAP therapy, with the specific type and settings tailored to the individual patient's needs, alongside comprehensive weight management and potentially supplemental oxygen therapy.
From the Research
Initial Intervention for Obesity Hypoventilation Syndrome
The most appropriate initial intervention for obesity hypoventilation syndrome (OHS) is a topic of ongoing research and debate.
- Studies have compared the effectiveness of different positive airway pressure (PAP) therapies, including continuous PAP (CPAP) and non-invasive ventilation (NIV) 2, 3, 4, 5, 6.
- A systematic review and meta-analysis found that CPAP and NIV were similarly effective in improving gas exchange, sleep quality, and quality of life in patients with OHS 2.
- However, the review also noted that CPAP may be a more cost-effective option, as it requires fewer resources than NIV 2.
- Another study found that NIV was more effective than lifestyle modification in improving daytime PaCO2, sleepiness, and polysomnographic parameters in patients with OHS without severe obstructive sleep apnea (OSA) 5.
- A network meta-analysis of different PAP interventions found that volume-targeted pressure support (VT-PS) and bi-level PAP with back-up rate (BPAP-BUR) were superior to other PAP interventions for reducing PaCO2 and improving subjective daytime somnolence 6.
Considerations for Initial Intervention
When selecting an initial intervention for OHS, several factors should be considered, including:
- The presence and severity of OSA
- The patient's age, lung function, and overall health status
- The patient's ability to tolerate and adhere to different PAP therapies
- The availability and cost of different PAP devices and therapies
- The potential benefits and risks of each intervention, including the risk of treatment failure and the need for ongoing monitoring and adjustment 2, 3, 4, 5, 6.