A. Start positive airway pressure and refer to a weight loss program

This patient is presenting with obesity hypoventilation syndrome (OHS), a disease defined by marked obesity, body mass index of at least 30 kg/m2 complicated by alveolar hypoventilation not attributable to another condition.1 Initial therapy should be to improve ventilation with noninvasive positive airway pressure along with a multidisciplinary approach to weight loss that may ultimately include bariatric surgery.1

The cardiac findings in this patient are not unusual in patients with OHS. Approximately half of patients with OHS will develop pulmonary hypertension, which over time can lead to RV dilatation and failure.2 This may be exacerbated further by LV hypertrophy and diastolic dysfunction, which is often present in patients who are morbidly obese.


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In this scenario, the patient is unlikely to respond to inhalers or nebulizer treatments. Starting bosentan for pulmonary hypertension would be inappropriate in this patient who likely has group III pulmonary hypertension that probably will respond to noninvasive positive airway pressure and weight loss. Right heart catheterization could be a reasonable option if the patient’s pulmonary pressures fail to improve with the interventions discussed above. Pulmonary embolism is not suspected given the slow progressive nature of his symptoms; however, if future workup of his pulmonary hypertension is indicated, it may be reasonable to obtain a ventilation perfusion scan to rule out chronic thromboembolic disease.

References

  1. Martin TJ. Treatment and prognosis of the obesity hypoventilation syndrome. UpToDate®. Waltham, Massachusetts. www.uptodate.com/contents/treatment-and-prognosis-of-the-obesity-hypoventilation-syndrome. Last updated December 19, 2017. Accessed December 27, 2017.
  2. Nolte J, Koehler U, Sohrabi AK, Canisius S, Baumann S, Vogelmeier CF. Reversible severe pulmonary hypertension in obesity hypoventilation and Mohr syndrome. Respiratory Medicine CME. 2011;4(1):30-32.

This article originally appeared on The Cardiology Advisor