Pickwickian Syndrome

Pickwickian Syndrome Definition

The Pickwickian syndrome is clinically known as Obesity Hypoventilation Syndrome. In this syndrome the characteristic feature is an imbalance of oxygen and carbon-di-oxide content in blood and leads to breathing difficulty. The hypoventilation term is used due to lack of air reach and excretes from lungs. The hypoventilation may arise at daytime and even during sleep at night and cause sleep apnea1.

Pickwickian Syndrome

The general incidence rate of Pickwickian syndrome is unknown, but almost 10% to 20% obese individual complaining about the symptoms of Pickwickian syndrome. The severity of the disease related problem can be solved by early diagnosis and treatment intervention. But the lack of awareness cause delayed diagnosis or negligence of treatment, which increase the complexity2.


Charles Dickens, the Author of ‘The Pickwick Papers’, mentioned a line “fat and red-faced boy in a state of somnolence”. The narrative is relatively similar to the symptoms of Pickwickian syndrome and therefore Obesity Hypoventilation Syndrome is termed as Pickwickian syndrome3.


The different identified features of Pickwickian syndrome are divided into two phase – daytime symptoms and nighttime symptoms.

Daytime Symptoms

Sleep insufficiency at night leads to daytime drowsiness,  fatigue, irritability and breathlessness, headache, depression1.

The significant sign of Pickwickian syndrome is a lower level of oxygen in the blood,  because of  alveolar hypoventilation (Paco2 is greater than or equal to 45 mm Hg and  Po2 is less than 70 mm Hg)4.

Nighttime Symptoms

At night the sleep is disturbed, as loud and frequent snoring arises during sleep, breathing is not continuous and irregular pause between breathing cycle arises. Even breathing can stop for a short interval during sleeping.  Some of the patients also have ‘sleep hypoventilation’.

The sign of ‘sleep hypoventilation’ can be explained as >10 mm Hg of sleeping Paco2 in compared with wakefulness and desaturation of oxygen during sleep also cause apnea4.

Following are some rare symptoms, which also may prominent in Pickwickian syndrome:

  • Flushed face which is characterized by feelings of warmth and fast reddening
  • Bluish tint to the skin
  • High blood pressure
  • Enlarged liver
  • Abnormally high red blood cell count


Pickwickian syndrome is specific to the obese individual, whose BMI is greater than or equal to 30kg/m2. The exact cause is unknown, but the excess fat causes hormonal imbalance and may affect efficient breathing process. The obesity causes extreme pressure into the  pulmonary system. In addition, the brain also unable to manage correctly the breathing mechanism. The scientist also has the assumption that genetic involvement is also a considerable factor for Pickwickian syndrome1,5.


The diagnosis of Pickwickian syndrome is started with physical examination and following findings:

  • Overweight
  • Bluish skin or cyanosis observed in lips, nail bed of finger and toes
  • The limbs are swollen
  • Shortness of breathing

Following tests are performed for confirmation and detect the underlying cause

  • Chest X-ray
  • CT scan
  • Pulmonary Function Tests or Lung function tests
  • Estimation of Arterial Blood Gas
  • Polysomnography is used for sleep study

By diagnosis of obstructive sleep apnea, the doctor can detect the Pickwickian syndrome case, as patients suffering from Pickwickian syndrome, have a high carbon dioxide level in their blood when they wake up6.


The initial treatment involves a lessening of the symptoms i.e. provision of breathing assistance. This can be possible by incorporation of mechanical ventilation.

The treatment providence is possible in doctor’s clinic or outpatient department in the hospital.

Options include:

  • Continuous Positive Airway Pressure (CPAP) is a non-invasive mechanical ventilation, in which a mast is fitted over a nose or nose and mouth during sleep
  • Oxygen therapy
  • Invasive position includes tracheostomy, in which opening in the neck is conducted and only applied in the severe case.

To get long-term benefits, it is always advisable to weight control and that effective for reversing Pickwickian syndrome7.


Delay diagnosis and untreated condition of Pickwickian syndrome lead to serious cardiovascular disease, severe disability, or death6.


The different possible complication associated with Pickwickian syndrome are all related to a lack of sleep and those are:

  • Depression
  • Increase risk of accidents
  • Lack of concentration increases the possibility of mistakes
  • Lack of libido
  • Cardiovascular-related complications, such as hypertension, pulmonary hypertension and cor pulmonale (Right-sided heart failure)7


  • The preventive measure can be taken by managing weight and obesity.
  • Non-invasive ventilation techniques are applied according to the doctor advice

ICD 9 code

ICD-9-CM 278.03 is a billable medical code use for indicating a diagnosis on a reimbursement claim of Pickwickian syndrome8.


  1. Obesity Hypoventilation Syndrome; Am J Respir Crit Care Med, Vol. 189, P15-P16, 2014. www.thoracic.org ATS Patient Education Series © 2014 American Thoracic Society; Online Available; Retrieve From: https://www.thoracic.org/patients/patient-resources/resources/obesity-hypoventilation-syndrome.pdf
  2. Littleton SW, Mokhlesi B.; The Pickwickian syndrome-obesity hypoventilation syndrome; Clin Chest Med. 2009 Sep;30(3):467-78, vii-viii. doi: 10.1016/j.ccm.2009.05.004; Online Available; Retrieve From: http://www.ncbi.nlm.nih.gov/pubmed/19700045
  3. Definition of Pickwickian syndrome (2016); Online Available; Retrieve From:http://www.medicinenet.com/script/main/art.asp?articlekey=4896
  4. Stephen W. Littleton, Babak Mokhlesi, The Pickwickian Syndrome—Obesity Hypoventilation Syndrome; DOI: http://dx.doi.org/10.1016/j.ccm.2009.05.004; Online Available; Retrieve From: http://www.chestmed.theclinics.com/article/S0272-5231(09)00050-1/abstract
  5. Pickwickian syndrome; Online Available; Retrieve From: http://medical-dictionary.thefreedictionary.com/pickwickian+syndrome
  6. What Is Obesity Hypoventilation Syndrome? (2012); Online Available; Retrieve From: https://www.nhlbi.nih.gov/health/health-topics/topics/ohs
  7. Pickwickian Syndrome; Online Available; Retrieve From: http://www.healthcentral.com/encyclopedia/hc/pickwickian-syndrome-3168515/
  8. Obesity hypoventilation syndrome; Online Available; Retrieve From: http://www.icd9data.com/2015/Volume1/240-279/270-279/278/278.03.htm

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