Look at this patient.



· Daytime somnolence.

· Unrefreshing sleep.

· Daytime fatigue.

· Snoring.

· Shortness of breath.

· Headache, particularly in the morning.

· Swelling of feet.

· Poor concentration.

· Systemic hypertension.

· Family history of obesity.

· Gastro-oesophageal reflux.

· Poor quality of life.


· Obese patient who is plethoric and cyanosed.

· Maxillary or mandibular hypoplasia.

· Shortness of breath at rest.

· May be nodding off to sleep.

· Systemic hypertension.

· Nocturnal angina.

· Look for signs of pulmonary hypertension and right heart failure.

Remember. Nearly 50% of patients with sleep apnoea syndrome are not obese.


This patient has marked obesity and hypersomnolence with signs of pulmonary hypertension (lesion) which indicate that she has

pickwickian syndrome. The patient is in cardiac failure (functional status).

Read reviews: J R Coil Phys (Lond) 1993; 27: 3634; J R Coil Phys (Lond) 1993; 27: 375.


What is the cause of cyanosis in such a patient?

A mixture of obstructive apnoea and sleep-induced hypoventilation. The blood gas picture is hypoxia and carbon dioxide retention.

Where is the obstruction?

It is caused by the apposition of the tongue and the palate on the posterior pharyngeal wall.

How would you treat such a patient?

· Weight reduction.

· Avoidance of smoking and alcohol.

· Progesterone (enhances respiratory drive).

· Continuous nasal positive airway pressure delivered by a nasal mask (lancet 1999; 353: 2100-5).

· Home oxygen.

· Surgery: tracheostomy, uvulopalatopharyngoplasty, linguoplasty, mandibular advancement, plastic remodelling of the uvula

(laser-assisted or radiofrequency ablation).

· Drugs: serotonin receptor blockade, acetazolamide, methylxanthines, weight loss medications.