Therapeutic approach in the management of Pickwickian syndrome: An updated review

Obesity hypoventilation syndrome (OHS) is a complex and underdiagnosed disorder that has emerged as a significant public health concern alongside the rising prevalence of obesity worldwide. It is defined by the presence of obesity, chronic daytime alveolar hypoventilation resulting in hypercapnia, and sleep-disordered breathing, in the absence of alternative causes of hypoventilation. Although diagnostic criteria are well established, OHS frequently remains unrecognized, leading to delayed treatment and increased risk of adverse clinical outcomes. The pathophysiology of OHS is multifactorial and involves an interplay between mechanical, neurophysiological, and metabolic factors. Excess adiposity imposes mechanical constraints on the respiratory system, reduces lung volumes, and increases the work of breathing. These changes are compounded by impaired ventilatory drive, respiratory muscle inefficiency, and altered leptin signaling. Sleep-related breathing disorders, particularly obstructive sleep apnea, are present in the majority of patients and contribute significantly to nocturnal hypoventilation and the development of sustained daytime hypercapnia. Clinically, OHS is associated with substantial morbidity, including pulmonary hypertension, right ventricular dysfunction, recurrent episodes of acute-on-chronic respiratory failure, and increased healthcare utilization. Diagnosis relies on the demonstration of daytime hypercapnia using arterial blood gas analysis, supported by polysomnography and exclusion of other causes of chronic respiratory failure. Early recognition is critical to prevent disease progression and irreversible cardiopulmonary complications. Management strategies are directed toward correcting hypoventilation, improving oxygenation, and addressing obesity. Positive airway pressure therapy represents the cornerstone of treatment, with modality selection guided by disease severity and response to therapy. Weight reduction through lifestyle interventions or bariatric surgery remains the only definitive approach capable of modifying the underlying disease process. This review provides a comprehensive synthesis of current evidence on the epidemiology, mechanisms, clinical features, diagnostic approach, and management of obesity hypoventilation syndrome, highlighting the importance of early diagnosis and individualized therapy to improve patient outcomes.