NICE guidance - treatments for obesity hypoventilation syndrome (OHS)

Last edited 09/2021 and last reviewed 10/2021

NICE guidance - treatments for obesity hypoventilation syndrome (OHS)

Lifestyle advice for all severities of obesity hypoventilation syndrome (OHS)

• discuss appropriate lifestyle changes with all people with OSAHS. Provide support and information on losing weight, stopping smoking, reducing alcohol intake and improving sleep hygiene, tailored to the person's needs and in line with the NICE guidelines on:
  • stop smoking interventions and services
  • preventing excess weight gain
  • obesity: identification, assessment and management (in particular, the section on lifestyle interventions)
  • alcohol-use disorders: prevention (in particular, recommendations on screening, brief advice and extended brief interventions for adults)

Treatments for obesity hypoventilation syndrome (OHS)

CPAP and non-invasive ventilation

People with OHS who do not have acute ventilatory failure

• offer continuous positive airway pressure (CPAP) to people with OHS and severe OSAHS as first-line treatment
• offer non-invasive ventilation as an alternative to CPAP for people with OHS and severe OSAHS if symptoms do not improve, hypercapnia persists, apnoea-hypopnoea index (AHI) or oxygen desaturation index (ODI) are not sufficiently reduced or CPAP is poorly tolerated
• consider non-invasive ventilation for people with OHS and nocturnal hypoventilation who do not have OSAHS, or in whom OSAHS is not severe
• consider heated humidification in addition to CPAP for people with OHS and OSAHS and upper airway side effects such as nasal and mouth dryness, and CPAP-induced rhinitis

People with OHS and acute ventilatory failure

• offer non-invasive ventilation to people with OHS with acute ventilatory failure:
  • if hypercapnia persists, consider continuing and further optimising non-invasive ventilation
  • if hypercapnia resolves, consider stopping non-invasive ventilation and monitoring the response
• after a person with OHS and acute ventilatory failure has been stabilised on non-invasive ventilation with control of hypercapnia, consider:
  • stopping non-invasive ventilation and carrying out respiratory polygraphy and
  • a trial of CPAP in people with frequent episodes of obstructive apnoea and minimal hypoventilation. If the person decompensates after stopping non-invasive ventilation, offer to restart non-invasive ventilation

Oxygen therapy

• consider supplemental oxygen therapy with CPAP or non-invasive ventilation for people with OHS who remain hypoxaemic despite optimal control of nocturnal hypoventilation and AHI on CPAP or non-invasive ventilation, and address any additional underlying causes of hypoxaemia where possible

Managing rhinitis in people with obesity hypoventilation syndrome (OHS)

Assess people with nasal congestion and OHS for underlying allergic or vasomotor rhinitis

If rhinitis is diagnosed in people with OHS, offer initial treatment with:

• topical nasal corticosteroids or antihistamines for allergic rhinitis or
• topical nasal corticosteroids for vasomotor rhinitis

For people with OHS and persistent rhinitis, consider referral to an ear, nose and throat specialist if:

• symptoms do not improve with initial treatment or
• anatomical obstruction is suspected

Be aware that:

• rhinitis can affect people's tolerance to CPAP and non-invasive ventilation but changing from a nasal to an orofacial mask and adding humidification can help (see recommendation 2.5.4 on heated humidification for OHS and OSAHS)
• CPAP and non-invasive ventilation can worsen or cause rhinitis and nasal congestion

Reference:

• NICE (August 2021). Obstructive sleep apnoea/hypopnoea syndrome and obesity hypoventilation syndrome in over 16s