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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.

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.

History

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.

Symptoms

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

Causes

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 syndrome^1,5.

Diagnosis

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.

Treatment

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.

Prognosis

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

Complications

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

Prevention

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.

References

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
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
Definition of Pickwickian syndrome (2016); Online Available; Retrieve From:http://www.medicinenet.com/script/main/art.asp?articlekey=4896
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
Pickwickian syndrome; Online Available; Retrieve From: http://medical-dictionary.thefreedictionary.com/pickwickian+syndrome
What Is Obesity Hypoventilation Syndrome? (2012); Online Available; Retrieve From: https://www.nhlbi.nih.gov/health/health-topics/topics/ohs
Pickwickian Syndrome; Online Available; Retrieve From: http://www.healthcentral.com/encyclopedia/hc/pickwickian-syndrome-3168515/
Obesity hypoventilation syndrome; Online Available; Retrieve From: http://www.icd9data.com/2015/Volume1/240-279/270-279/278/278.03.htm

Pickwickian Syndrome