Noninvasive Ventilation versus CPAP as Initial Treatment of Obesity Hypoventilation Syndrome: A Systematic Review. Journal Article

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Authors: Soghier, I; Brozek, JL; Afshar, M; Tamae Kakazu, M; Wilson, KC; Masa, JF; Mokhlesi, B
Article Title: Noninvasive Ventilation versus CPAP as Initial Treatment of Obesity Hypoventilation Syndrome: A Systematic Review.
Abstract: RATIONALE: Obesity hypoventilation syndrome (OHS) is an undesirable consequence of obesity. Treatment consists of weight loss and positive airway pressure (PAP) therapy. However, the preferred mode of PAP is uncertain. OBJECTIVE: To perform a systematic review to determine whether PAP therapy should be initiated as noninvasive ventilation (NIV) or continuous positive airway pressure (CPAP) in ambulatory patients with OHS. METHODS: This systematic review informed an international, multi-disciplinary panel of experts who had converged to develop a clinical practice guideline on OHS for the American Thoracic Society. Medline, the Cochrane Library, and Embase were searched from January 1946 to March 2019 for studies that compared initial treatment with NIV to CPAP in OHS. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach was used to appraise the quality of evidence. RESULTS: The search identified 2,994 potentially relevant articles, the full text of 21 articles was reviewed, and five articles were selected. The five articles included three randomized trials (one reported as two articles) and an observational study. Sample size ranged from 36 to 225 subjects. The evidence found no differences in mortality, cardiovascular events, and healthcare resource utilization between patients with OHS treated with NIV or CPAP. Both PAP modalities were similarly effective in improving gas exchange, need for supplemental oxygen, daytime sleepiness, sleep quality, quality of life, dyspnea and sleep-disordered breathing. There was also no significant difference in adherence to NIV or CPAP therapy. Certainty in the estimated effects was low or very low for some outcomes. Therefore, the conditional recommendation was based on very low-quality evidence. CONCLUSION: The panel made a conditional (i.e., weak) recommendation that CPAP rather than NIV be offered as the first line treatment to stable ambulatory patients with OHS and coexistent severe obstructive sleep apnea (OSA). The effectiveness of CPAP is similar to NIV, but NIV is more costly and requires more resources than CPAP. Given that approximately 70% of patients with OHS have co-existent severe OSA, this recommendation applies to the great majority of patients with stable OHS, but it should not be extrapolated to OHS patients without severe OSA. Patients with advanced age, poor lung function, greater or recent acute ventilatory failure may not respond adequately to CPAP.
Journal Title: Annals of the American Thoracic Society
ISSN: 2325-6621; 2325-6621
Publisher: Unknown  
Date Published: 2019