Pickwickian Syndrome

What is Pickwickian Syndrome really?

Pickwickian Syndrome, also called obesity hypoventilation syndrome, is a complex of respiratory and circulatory symptoms associated with severe obesity. The name most likely originates from the fat young lad depicted in Charles Dickens’s story The Pickwick  Papers, who showed some of the identical negative health qualities. By some definitions, to be obese is to exceed one’s perfect weight by 20 percent or more; an extremely obese individual would exceed the optimum weight by a much larger percentage. This condition often occurs in connection with sleep apnea, which is an additional common complication of obesity.

In pickwickian syndrome the velocity of breathing is persistently decreased below the normal level. Because of too little removal of carbon dioxide by the lungs, levels of carbon dioxide in the blood raise, leading to respiratory acidosis. In more difficult instances, oxygen in the blood is also significantly reduced.

Individuals who have pickwickian syndrome often complain of insidiously slow thinking, drowsiness, and fatigue. Low blood oxygen causes the small blood vessels entering the lungs to constrict, thus increasing pressure in the vessels that supply the lungs. The elevated pressure stresses the right ventricle of the heart, eventually causing right side heart failure. Finally, disproportionate fluid accumulates throughout the body (peripheral edema), especially beneath the skin of the lower legs.

Evidence suggests the pickwickian syndrome is connected with significant mortality and morbidity. Two older case series, published before treatment options became accessible and before the customary use of in-hospital heparin prophylaxis, reported high in-hospital mortality rates principally related to progressive respiratory failure or acute pulmonary embolism.

A current study found hospitalized patients had a higher 18-month mortality rate of 23% compared with 9% among sufferers with straightforward obesity. Notably, although healthcare providers were informed of the obesity-associated hypo-ventilation, only 13% of patients.

Is Obesity Hypo-Ventilation the same thing?

Patients with obesity hypoventilation (related to pickwickian syndrome) may present with unexplained hypoxemia or a broad spectrum of symptoms ranging from hyper-somnolence or dyspnea to signs of right-sided congestive heart failure. Because these patients have a concurrent sleep-related breathing disorder with sleep induced exaggeration of hyper-capnia and hypoxemia and recurrent arousals from sleep, presenting symptoms may include exhaustion, hyper-somnolence, mood disorders, and nocturnal or morning headaches. In patients with apneic or hypopneic events, symptoms may include loud snoring, choking, gagging, and resuscitative snorting. Untreated sufferers may develop secondary erythrocytosis and will ultimately develop pulmonary hypertension and cor pulmonale.

Data suggest that obesity hypoventilation syndrome is under-recognized and under-treated. We believe the diagnosis is frequently missed because pulse oximetry is used to detect oxyhemoglobin desaturation without consideration for the presence of hypercapnia.

As a result, patients may be inappropriately treated with supplemental oxygen alone, which does not reverse hypoventilation.