When obesity turns critical: How obesity hypoventilation syndrome can lead to respiratory failure and what you can do to prevent it

In a complex and high-risk critical care intervention, the multi-disciplinary ICU team at CK Birla Hospital, Gurugram managed and extubated a 160 kg woman, who was suffering from Obesity Hypoventilation Syndrome (OHS). It’s a serious breathing disorder seen in people with obesity, where the body fails to breathe deeply or effectively enough due to chronically high carbon dioxide levels and low oxygen levels in the blood. The patient was discharged in stable condition within days of her admission.

The 75-year-old patient, who had co-morbidities such as diabetes, hypertension, anxiety and bedsores due to extreme obesity, arrived at the emergency room severe respiratory failure due to bilateral pneumonia compounded by acute decompensated congestive heart failure. She required immediate mechanical ventilation as her NT-proBNP levels were above 10,000, indicating severe cardiac strain.






Within the first 24 hours of intensive ICU management, her infection markers, fever, and chest X-ray showed improvement, and cardiac markers began trending downward. Based on these encouraging signs, the medical team planned extubation (removing the breathing tube (endotracheal tube) from a patient’s airway) approximately 36 hours after initial intubation. However, immediately after removal of ventilatory support, the patient developed severe hypoxia and crashed, necessitating urgent re-intubation.

Dr Kuldeep Kumar Grover, Associate Director – Pulmonology & Critical Care, CK Birla Hospital, Gurugram, said, “The sudden deterioration was linked to obesity-related ventilatory restriction, consistent with OHS, also known as Pickwickian syndrome. In morbidly obese patients, lung compliance is markedly reduced, functional residual capacity falls and respiratory reserve become critically limited. Even when oxygenation parameters appear stable on the ventilator, these patients may not sustain spontaneous breathing once support is withdrawn, making extubation particularly high risk.”

Dr Grover further added that in this patient’s case, although her infection markers and cardiac parameters were improving, her underlying obesity significantly compromised her ability to maintain adequate tidal volumes independently.

“The initial extubation failure highlighted how deceptive clinical stability can be in such patients. We recalibrated our approach with prolonged spontaneous breathing trials, graded pressure support, and bronchoscopy-guided airway preparedness. That cautious, protocol-driven strategy ultimately enabled a safe and successful second extubation,” he said.

OHS is increasingly being recognised in India alongside rising obesity rates. Indian studies have reported prevalence rates ranging from approximately 5-16% among patients evaluated for sleep-disordered breathing. Despite this, the condition remains underdiagnosed until patients present with acute respiratory or cardiac decompensation.

The case underscores the rising burden of obesity-related respiratory and cardiac emergencies and highlights the importance of protocol-driven ICU management in high-risk extubations. Doctors emphasize that early screening, weight management, and regular medical follow-ups are crucial to prevent such life-threatening crises.