eMedicine Specialties > Pediatrics: General Medicine > Pulmonology

Obesity-Hypoventilation Syndrome and Pulmonary Consequences of Obesity: Differential Diagnoses & Workup

Author: Mary E Cataletto, MD, Associate Director, Division of Pediatric Pulmonology, Winthrop University Hospital; Professor of Clinical Pediatrics, State University of New York at Stony Brook; Director of Children's Sleep Services, Winthrop University Hospital
Coauthor(s): Gila Hertz, PhD, ABSM, Director, Center for Insomnia and Sleep Disorders, Clinical Associate Professor of Psychiatry and Behavioral Sciences, State University of New York at Stony Brook
Contributor Information and Disclosures

Updated: Nov 25, 2008

Differential Diagnoses

Beckwith-Wiedemann Syndrome
Prader-Willi Syndrome
Sleep Apnea

Other Problems to Be Considered

Narcolepsy
Use (abuse) of sedatives and antihistamines
Sleep deprivation
Obstructive sleep apnea
Sleep-related breathing disorders

Workup

Laboratory Studies

  • Obesity-hypoventilation syndrome may be associated with daytime hypoxemia and hypercarbia.
  • Response to carbon dioxide is decreased in obstructive sleep apnea (OSA).
  • Hematocrit levels may be elevated in children with chronic hypoxemia.

Imaging Studies

  • Chest radiography: Specifically note evidence of chest wall deformities, heart size, and evidence of congestive heart failure.
  • Echocardiography: Right ventricular hypertrophy can be observed with sleep apnea (OSA) and hypoventilation or hypopnea (OSA/H) in association with chronic hypoxemia.

Other Tests

  • Pulmonary functions studies
    • Flow volume loop: The sawtooth pattern associated with upper airway obstruction may be observed.
    • Spirometry: In a study by Mallory et al, most children (58%) had abnormal pulmonary function findings, which were primarily obstructive in nature.4 Fung et al's data showed significant changes in forced vital capacity (FVC) in boys who were overweight but not in girls who were overweight.5 This is consistent with the finding that fat distribution in adolescents who are overweight and obese differs from that seen in adults and is gender specific. Boys tend to accumulate fat in the abdominal area, whereas girls tend to accumulate fat in the subscapular area.
    • Maximum voluntary ventilation may be decreased.
    • Lung volumes: Patterns of fat distribution differ in adolescents who are overweight and obese. Because of the impact of the abdominal fat on the diaphragm, the expiratory reserve volume (ERV) is decreased, and, as a result, the FVC is also decreased. Adult studies show the ERV to be severely decreased in patients with extreme and morbid obesity. Biring et al along found ERV to be the most sensitive indicator of obesity.6 Many reasons have been offered in addition to the mass effect on the position of the diaphragm. These include decreased diaphragmatic mobility, decreased respiratory compliance, decreased respiratory muscle strength, and fatty infiltration of the respiratory muscles.
    • Diffusion: Results have varied. Inselma et al reported children with decreased diffusing capacity of lung for carbon monoxide (DLCO).7 By contrast, Biring et al studied a group of patients aged 13-78 years and reported that the DLCO and alveolar volume were normal, except in those who were extremely obese.6
    • Airway resistance may be increased.
    • Inspiratory and expiratory pressures were normal in Inselma et al's study.7
  • Overnight polysomnography: In children and adolescents, morbid obesity can be associated with hypoventilation, hypoxia, and hypercarbia during sleep. Others may present with evidence of obstructive sleep apnea.
  • Multiple sleep latency test: The multiple sleep latency test (MSLT) can be useful in the evaluation of patients complaining of excessive daytime sleepiness. The MSLT is performed on the day following the overnight polysomnogram. Its findings can be used to assess pathological sleepiness and contribute to a diagnosis of narcolepsy.
  • Electrocardiography: Cardiac dysrhythmias and right bundle branch block (RBBB) have been reported.

More on Obesity-Hypoventilation Syndrome and Pulmonary Consequences of Obesity

Overview: Obesity-Hypoventilation Syndrome and Pulmonary Consequences of Obesity
Differential Diagnoses & Workup: Obesity-Hypoventilation Syndrome and Pulmonary Consequences of Obesity
Treatment & Medication: Obesity-Hypoventilation Syndrome and Pulmonary Consequences of Obesity
Follow-up: Obesity-Hypoventilation Syndrome and Pulmonary Consequences of Obesity
Multimedia: Obesity-Hypoventilation Syndrome and Pulmonary Consequences of Obesity
References
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References

  1. Shields M. Overweight and obesity among children and youth. Health Rep. Aug 2006;17(3):27-42. [Medline].

  2. Eneli I, Dele Davis H. Epidemiology of Childhood Obesity. In: Dele Davis H. Obesity in Childhood & Adolescence. Vol 1. Westport, CT: Praeger Perspectives; 2008:3-19.

  3. Rosen CL. Clinical features of obstructive sleep apnea hypoventilation syndrome in otherwise healthy children. Pediatr Pulmonol. Jun 1999;27(6):403-9. [Medline].

  4. Mallory GB Jr, Fiser DH, Jackson R. Sleep-associated breathing disorders in morbidly obese children and adolescents. J Pediatr. Dec 1989;115(6):892-7. [Medline].

  5. Fung KP, Lau SP, Chow OK, Lee J, Wong TW. Effects of overweight on lung function. Arch Dis Child. May 1990;65(5):512-5. [Medline].

  6. Biring MS, Lewis MI, Liu JT, Mohsenifar Z. Pulmonary physiologic changes of morbid obesity. Am J Med Sci. Nov 1999;318(5):293-7. [Medline].

  7. Inselma LS, Milanese A, Deurloo A. Effect of obesity on pulmonary function in children. Pediatr Pulmonol. Aug 1993;16(2):130-7. [Medline].

  8. Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma-Summary Report 2007. J Allergy Clin Immunol. Nov 2007;120(5 Suppl):S94-138. [Medline].

  9. Coleman J. Disordered breathing during sleep in newborns, infants, and children. Symptoms, diagnosis, and treatment. Otolaryngol Clin North Am. Apr 1999;32(2):211-22. [Medline].

  10. Erler T, Paditz E. Obstructive sleep apnea syndrome in children: a state-of-the-art review. Treat Respir Med. 2004;3(2):107-22. [Medline].

  11. Goble M. Medical and Psychological Complications of Obesity. In: Dele Davis H (ed). Obesity in Childhood & Adolescence. Westport, CT: Praeger Perspectives; 2008:229-257.

  12. Han F, Chen E, Wei H, He Q, Ding D, Strohl KP. Treatment effects on carbon dioxide retention in patients with obstructive sleep apnea-hypopnea syndrome. Chest. Jun 2001;119(6):1814-9. [Medline].

  13. Hudgel DW, Thanakitcharu S. Pharmacologic treatment of sleep-disordered breathing. Am J Respir Crit Care Med. Sep 1998;158(3):691-9. [Medline].

  14. Levy P, Pepin JL, Arnaud C, et al. Intermittent hypoxia and sleep-disordered breathing: current concepts and perspectives. Eur Respir J. Oct 2008;32(4):1082-95. [Medline].

  15. Marcus CL, Curtis S, Koerner CB, et al. Evaluation of pulmonary function and polysomnography in obese children and adolescents. Pediatr Pulmonol. Mar 1996;21(3):176-83. [Medline].

  16. Marcus CL, Gozal D, Arens R, et al. Ventilatory responses during wakefulness in children with obstructive sleep apnea. Am J Respir Crit Care Med. Mar 1994;149(3 Pt 1):715-21. [Medline].

  17. Perkin RM, Downey R 3rd, Macquarrie J. Sleep-disordered breathing in infants and children. Respir Care Clin N Am. Sep 1999;5(3):395-426, viii. [Medline].

  18. Rhodes SK, Shimoda KC, Waid LR, et al. Neurocognitive deficits in morbidly obese children with obstructive sleep apnea. J Pediatr. Nov 1995;127(5):741-4. [Medline].

  19. Schonfeld-Warden N, Warden CH. Pediatric obesity. An overview of etiology and treatment. Pediatr Clin North Am. Apr 1997;44(2):339-61. [Medline].

  20. Silvestri JM, Weese-Mayer DE, Bass MT, et al. Polysomnography in obese children with a history of sleep-associated breathing disorders. Pediatr Pulmonol. Aug 1993;16(2):124-9. [Medline].

  21. Strauss R. Childhood obesity. Curr Probl Pediatr. Jan 1999;29(1):1-29. [Medline].

  22. Tantisira KG, Litonjua AA, Weiss ST, et al. Association of body mass with pulmonary function in the Childhood Asthma Management Program (CAMP). Thorax. Dec 2003;58(12):1036-41. [Medline].

  23. Zwillich CW, Sutton FD, Pierson DJ, et al. Decreased hypoxic ventilatory drive in the obesity-hypoventilation syndrome. Am J Med. Sep 1975;59(3):343-8. [Medline].

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Further Reading

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Keywords

obesity, hypoventilation syndrome, Pickwick syndrome, pickwickian syndrome, obstructive sleep apnea/hypoventilation, OSA/H, obstructive sleep apnea, hypoventilation, sleep-disordered breathing, hypercarbia, excessive daytime sleepiness, hyperactivity, cor pulmonale, failure to thrive, mental retardation, tonsillar hypertrophy, diabetes, hypertension, gallstones, hypercholesterolemia, reactive airways, poor exercise tolerance, increased work of breathing, increased oxygen consumption, right-sided heart failure, upper respiratory infections, snoring, parasomnias, chronic mouth breathing, asthma, short stature, developmental delay, macroglossia, retrognathia, micrognathia, high-arched palate, thoracic kyphosis, pectus excavatum, scoliosis, abdominal obesity, ankle edema, congestive heart failure

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Contributor Information and Disclosures

Author

Mary E Cataletto, MD, Associate Director, Division of Pediatric Pulmonology, Winthrop University Hospital; Professor of Clinical Pediatrics, State University of New York at Stony Brook; Director of Children's Sleep Services, Winthrop University Hospital
Mary E Cataletto, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Chest Physicians
Disclosure: Shering Plough Pharmaceuticals Honoraria Consulting

Coauthor(s)

Gila Hertz, PhD, ABSM, Director, Center for Insomnia and Sleep Disorders, Clinical Associate Professor of Psychiatry and Behavioral Sciences, State University of New York at Stony Brook
Gila Hertz, PhD, ABSM is a member of the following medical societies: American Academy of Sleep Medicine and American Psychological Association
Disclosure: Nothing to disclose.

Medical Editor

Girish D Sharma, MD, Associate Professor, Department of Pediatrics, Rush University Medical Center, Rush Children's Hospital; Director of Pediatric Pulmonary Section and Rush Cystic Fibrosis Center
Girish D Sharma, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society, and Royal College of Physicians of Ireland
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from broker recommendation; Avanir Pharma Stock Investment from broker recommendation

Managing Editor

Charles Callahan, DO, Professor, Deputy Chief of Clinical Services, Walter Reed Army Medical Center
Charles Callahan, DO is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American College of Osteopathic Pediatricians, American Thoracic Society, Association of Military Surgeons of the US, and Christian Medical & Dental Society
Disclosure: Nothing to disclose.

CME Editor

Daniel Rauch, MD, FAAP, Director, Pediatric Hospitalist Program, Associate Professor, Department of Pediatrics, New York University School of Medicine
Daniel Rauch, MD, FAAP is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, and Society of Hospital Medicine
Disclosure: Baxter Honoraria Consulting; Pfizer Honoraria Consulting

Chief Editor

Michael R Bye, MD, Professor of Clinical Pediatrics, Division of Pulmonary Medicine, Columbia University College of Physicians and Surgeons; Attending Physician, Pediatric Pulmonary Medicine, Columbia University Medical Center
Michael R Bye, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, and American Thoracic Society
Disclosure: Merck Honoraria Speaking and teaching

 
 
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