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Sleep Disorders

Pickwickian Syndrome

09/06/2011

Question:

What is Pickwickian syndrome?

Answer:

The term Pickwickian syndrome is often misused to describe a variety of sleep disorders involving breathing disturbances in sleep, leading to some confusion. The term really should be used only to describe a specific set of symptoms that include obesity (usually morbid obesity), excessive sleepiness and hypoventilation (elevation of the carbon dioxide level). Almost all individuals with this set of symptoms have obstructive sleep apnea (OSA).

The major cause of the constellation of symptoms is the obesity. The excessive weight places a significant mechanical stress on the breathing system, resulting in hypoventilation, or inability to breath deep enough, leading to chronic retention of carbon dioxide (CO2). Increases in CO2 can lead to the sensation of shortness of breath as well as lead to lower oxygen levels in the lungs and blood. This can be harmful over time and places the individual at risk for heart problems, especially right sided heart failure.

The obesity also places the individual at risk for OSA. OSA is defined as repetitive episodes of airway narrowing or collapse during sleep. During sleep, the muscles supporting the upper airway in the back of the throat tend to relax. When individuals with a narrowed airway to start with fall asleep, this muscle relaxation may be enough to cause significant narrowing or collapse of the tissue in the back of the throat. A narrowed airway is most commonly the result of being overweight as fatty tissue tends to deposit in the tissues of the airway.

When the airway collapses in OSA, the brain and body protect themselves by making the individual briefly awaken (most people who do this are not aware of this happening) and opening their airway to allow for normal breathing. Unfortunately, as they fall back asleep, the process of airway closure tends to repeat over and over. These recurrent awakenings fragment or break up sleep, resulting in poor sleep, a lack of feeling refreshed after sleep and daytime sleepiness (hence the reason individuals with Pickwickian Syndrome are so sleepy). Other symptoms of OSA may include a sensation of choking or gasping in sleep, restless sleep and morning headaches. Loud snoring often accompanies the sleep disordered breathing.

Not only does the poor sleep affect quality of life, but OSA has now been linked to numerous other problems if it goes unrecognized and untreated for a prolonged time period. Most concerning of these conditions are high blood pressure and cardiovascular disease (for example stroke and heart disease). OSA is treatable by a number of methods and the type of treatment best suited for each individual depends upon a number of factors.

Untreated, Pickwickian syndrome can lead to serious cardiac and pulmonary disease that, in some cases, can be fatal. The good news is that if detected and appropriately treated, it can be reversed. Aside from weight loss, there are a number of treatments used to help prevent complications associated with Pickwickian Syndrome. These include the use of oxygen if indicated, treatment of OSA, and medications to optimize heart function and fluid status.

Of interest, this term came from a Charles Dickens novel, The Pickwick Papers, in which one of the characters ("fat boy Joe") had the constellation of symptoms that now make up the Pickwickian Syndrome. If you are concerned you might have Pickwickian Syndrome, you should discuss this with your doctor. Referral to a Pulmonologist and / or Sleep Specialist may be necessary to ensure the appropriate testing and treatment are performed.

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Response by:

Dennis   Auckley, MD Dennis Auckley, MD
Associate Professor of Medicine
School of Medicine
Case Western Reserve University