The Effect of Hospital Discharge with Empiric Noninvasive Ventilation on Mortality in Hospitalized Patients with Obesity Hypoventilation Syndrome. An Individual Patient Data Meta-Analysis

• Published in: Annals of the American Thoracic Society Vol. 17; no. 5; pp. 627 - 637
• Main Authors: Mokhlesi, Babak, Masa, Juan Fernando, Afshar, Majid, Almadana Pacheco, Virginia, Berlowitz, David J, Borel, Jean-Christian, Budweiser, Stephan, Carrillo, Andres, Castro-Añón, Olalla, Ferrer, Miquel, Gagnadoux, Frédéric, Golpe, Rafael, Hart, Nicholas, Howard, Mark E, Murphy, Patrick B, Palm, Andreas, Perez de Llano, Luis A, Piper, Amanda J, Pépin, Jean Louis, Priou, Pascaline, Sánchez-Gómez, Jesús F, Soghier, Israa, Tamae Kakazu, Maximiliano, Wilson, Kevin C
• Format: Journal Article
• Language: English
• Published: United States American Thoracic Society 01.05.2020
• Subjects: Adult; Airway management; Cellular Biology; Controlled Clinical Trials as Topic; Food and Nutrition; Human health and pathology; Humans; Inpatient care; Life Sciences; Medical diagnosis; Meta-analysis; Noninvasive Ventilation - standards; Obesity; Obesity Hypoventilation Syndrome - complications; Obesity Hypoventilation Syndrome - therapy; Patient Discharge - standards; Patient Discharge - statistics & numerical data; Pharmaceutical sciences; Practice Guidelines as Topic; Pressure; Quality of Life; Respiratory diseases; Respiratory failure; Respiratory Insufficiency - mortality; Pickwickian; hypercarbia; continuous positive airway pressure; positive airway pressure; hypercapnia
• ISSN: 2329-6933; 2325-6621
• DOI: 10.1513/AnnalsATS.201912-887OC

Hospitalized patients with acute-on-chronic hypercapnic respiratory failure due to obesity hypoventilation syndrome (OHS) have increased short-term mortality. It is unknown whether prescribing empiric positive airway pressure (PAP) at the time of hospital discharge reduces mortality compared with waiting for an outpatient evaluation (i.e., outpatient sleep study and outpatient PAP titration). An international, multidisciplinary panel of experts developed clinical practice guidelines on OHS for the American Thoracic Society. The guideline panel asked whether hospitalized adult patients with acute-on-chronic hypercapnic respiratory failure suspected of having OHS, in whom the diagnosis has not yet been made, should be discharged from the hospital with or without empiric PAP treatment until the diagnosis of OHS is either confirmed or ruled out. A systematic review with individual patient data meta-analyses was performed to inform the guideline panel's recommendation. Grading of Recommendations, Assessment, Development, and Evaluation was used to summarize evidence and appraise quality. The literature search identified 2,994 articles. There were no randomized trials. Ten studies met study selection criteria, including two nonrandomized comparative studies and eight nonrandomized noncomparative studies. Individual patient data on hospitalized patients who survived to hospital discharge were obtained from nine of the studies and included a total of 1,162 patients (1,043 discharged with PAP and 119 discharged without PAP). Empiric noninvasive ventilation was prescribed in 91.5% of patients discharged on PAP, and the remainder received empiric continuous PAP. Discharge with PAP reduced mortality at 3 months (relative risk 0.12, 95% confidence interval 0.05-0.30, risk difference -14.5%). Certainty in the estimated effects was very low. Hospital discharge with PAP reduces mortality following acute-on-chronic hypercapnic respiratory failure in patients with OHS or suspected of having OHS. Well-designed clinical trials are needed to confirm this finding.