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Published by American Thoracic Society · GRADE
This official American Thoracic Society clinical practice guideline aims to optimize the evaluation and management of adults with obesity hypoventilation syndrome (OHS). Using the GRADE methodology, the multidisciplinary panel formulated five conditional recommendations regarding diagnostic screening with serum bicarbonate, the application of positive airway pressure (PAP) therapy (CPAP or NIV) for both stable outpatient and hospitalized individuals, and the necessity of targeted, sustained weight loss interventions.
Key Takeaways
This version of the article was updated on November 15, 2019, with corrections listed in a published erratum (Am J Respir Crit Care Med 2019;200:1325–1326; DOI: 10.1164/rccm.v200erratum7).
For obese patients with sleep-disordered breathing with a high pretest probability of having OHS, we suggest measuring PaCO2 rather than serum bicarbonate or SpO2 to diagnose OHS.
For patients with low to moderate probability of having OHS (<20%), we suggest using serum bicarbonate level to decide when to measure PaCO2: in patients with serum bicarbonate <27 mmol/L, clinicians might forego measuring PaCO2, as the diagnosis of OHS in them is very unlikely; in patients with serum bicarbonate >27 mmol/L, clinicians might need to measure PaCO2 to confirm or rule out the diagnosis of OHS.
We suggest that clinicians avoid using SpO2 during wakefulness to decide when to measure PaCO2 in patients suspected of having OHS until more data about the usefulness of SpO2 in this context become available.
For stable ambulatory patients diagnosed with OHS, we suggest treatment with PAP during sleep.
For stable ambulatory patients diagnosed with OHS and concomitant severe OSA (apnea–hypopnea index > 30 events/h), we suggest initiating first-line treatment with CPAP therapy rather than NIV.
We suggest that hospitalized patients with respiratory failure suspected of having OHS be started on NIV therapy before being discharged from the hospital, until they undergo outpatient workup and titration of PAP therapy in the sleep laboratory, ideally within the first 3 mo after hospital discharge.
For patients with OHS, we suggest using weight-loss interventions that produce sustained weight loss of 25–30% of actual body weight. This level of weight loss is most likely required to achieve resolution of hypoventilation.
Clinical Topic
Obesity Hypoventilation Syndrome
Objectives
To optimize evaluation and management of patients with obesity hypoventilation syndrome (OHS).
Target Patient Population
Obese adults and patients with sleep-disordered breathing suspected of or diagnosed with OHS.
Diagnostic Criteria
Obesity (BMI > 30 kg/m2), sleep-disordered breathing (SDB), and awake daytime hypercapnia (awake resting PaCO2 > 45 mm Hg at sea level), after excluding other causes for hypoventilation.
Target Providers
Therapeutic Area
Respiratory and Sleep DisordersGuideline Scope
Care Settings
Special Populations
System: GRADE
Evidence Distribution
Evidence Levels
Recommendation Strength
Monitoring Guidance
Overnight monitoring should include continuous oximetry. Provide early (4-8 wk) follow-up to assess clinical/physiological response to PAP and monitor objective adherence to therapy.
Difficulty
advanced
Learning Paths