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Background Obesity-hypoventilation syndrome (OHS) is defined as a combination of obesity (BMI of ≥30 kg/m 2), raised PaCO2 when awake, and breathing abnormality during sleep with or without obstructive sleep apnoea (OSA).1Patients can present to hospital in acute hypercapnic respiratory failure. The mainstay of acute treatment of such patient remains stabilisation with acute non-invasive ventilation (NIV) and consideration of home ventilation. However, long term management should include weight-loss intervention.1 With the improved evidence base supporting weight-loss pharmacotherapy, and improved access to such treatments,2 it is crucial that patients appropriate for these interventions are identified. Currently little is known about the number of OHS patients that meet eligibility for these drugs.Methods We conducted a retrospective analysis of patients admitted to a single-centre Respiratory Support Unit (June-December 2024) with OHS requiring acute NIV, including patients with comorbid conditions (e.g. COPD) but where OHS was the principal diagnosis. Clinical notes were reviewed for weight loss interventions offered during admission. Tirzepatide eligibility by both NHS England 2025 criteria (BMI ≥40 with 4 of 5 obesity related health conditions; diabetes, hypertension, hypercholesterolaemia, ischaemic heart disease, OSA) and proposed 2026 criteria (BMI ≥30 with 3 of those 5 conditions).Result Among 377 admissions, 35 patients (9.3%) had OHS and were included. Only 3 (9%) were offered weight loss intervention/advice during admission. One patient was offered referral to a structured weight management programme. 10 patients (29%) met the 2025 criteria for Tirzepatide, whilst 21 (60%) would meet the proposed 2026 criteria.Conclusion These findings demonstrate an emphasis on acute treatment for decompensated OHS but with a lack of long-term weight management strategies, despite evidence linking weight loss to improved outcomes. With the advent of weight-loss pharmacotherapy identifying appropriate patients promptly is essential. We have demonstrated that around 1/3 patients presenting with decompensated OHS meet current criteria for Tirzepatide. With the proposed expansion of criteria in 2026, it is likely that 2/3 patients will be eligible. Respiratory and primary care teams urgently need to develop robust pathways to ensure appropriate access to evidence based treatments for this overlooked patient group.References https://www.nice.org.uk/guidance/ng202/resourceshttps://www.nice.org.uk/guidance/ta1026/chapter/3-Committee-discussion#clinical-evidence