Two patients with the
Pickwickian syndrome and with life-threatening sleep
hypoxemia were treated with
continuous positive airway pressure (CPAP) applied through the nares only during sleep periods. Each patient presented with severe
daytime somnolence, disturbed sleep, nocturnal
confusion, and daytime awake cardiorespiratory failure (PaCO2, 63 and 55 mmHg). Both patients demonstrated grossly abnormal breathing during sleep with severe sleep
hypoxemia, the arterial
oxyhemoglobin saturation (SaO2%) falling repetitively to levels below 50%. One patient had a hypoxemic convulsion during the initial sleep evaluation. Low levels (3.5 and 8.0 cm H2O) of
continuous positive airway pressure, when applied via a comfortable nose mask, prevented occlusive
apnea and obstructive hypopnea during sleep in both patients and maintained steady levels of arterial
oxyhemoglobin saturation. There was rapid recovery of mental function and loss of cardiorespiratory failure within 3 days of treatment. After short-term treatment with nocturnal CPAP
therapy (23 days and 35 days) both patients were able to sleep, unaided, without sleep-induced upper airway occlusion with arterial
oxyhemoglobin levels sustained above 80%. We conclude that nasal CPAP
therapy during sleep is an effective noninvasive
therapy for patients with the
Pickwickian syndrome, and may lead to a stable remission of the underlying severe disordered breathing in sleep.