Indications and evidence for domiciliary noninvasive ventilation

ABSTRACT

Introduction

Home noninvasive ventilation (HNIV) has expanded globally, with a greater evidence base for its use. HNIV improves multiple patient related outcomes in patients with chronic hypercapnic respiratory failure. Obesity hypoventilation syndrome (OHS) is rapidly taking over as the primary indication for HNIV and COPD patients who overlap with obstructive sleep apnea hypoventilation syndromes (OSAHS) and are increasingly recognized but add to the complexity of HNIV prescribing. Optimal settings vary for differing diseases, with higher inspiratory pressures often required in those with OHS and COPD, yet which settings translate into greatest patient benefit remains unknown.

Areas covered

We cover the evidence base underpinning the common indications for HNIV in COPD, OHS, neuromuscular disease (NMD), and chest wall disease (CWD) and highlight common HNIV modes used.

Expert opinion

Active screening for nocturnal hypoventilation in OHS and COPD may be important to guide earlier ventilation. Further research on which HNIV modalities best improve patient related outcomes and the right time for initiation in different patient phenotypes is rapidly needed. Worldwide, clinical research trials should aim to bridge the gap by reporting on patient-related outcomes and cost effectiveness in real-world populations to best understand the true benefit of HNIV amongst heterogenous patient populations.

KEYWORDS:

• Non-invasive ventilation
• hypercapnia
• respiratory failure
• COPD
• OHS
• neuromuscular disease
• chest wall disease

Article highlights

• We summarize the evidence for the commonest diseases (COPD, OHS, NMD, and CWD) in regards to indications for HNIV

• Although evidence of patient benefit with NHIV is seen, we highlight this is limited by selected patient phenotypes, physiology and outcomes that are investigated in clinical trials and highlight the differences in real world patients.

• We must remember that the ‘one size’ approach does not meet the needs for all patients.

• We suggest that screening for clinical symptoms and physiological evidence suggestive of nocturnal hypoventilation and/or sleep disordered breathing earlier is key, such that we may better understand when HNIV is best started for patients to ensure clinically meaningful benefit.

• We highlight patient adherence to treatment remains a big challenge and that remote monitoring through automated technologies may be crucial to supporting adherence.

• Automated technologies not only need to offer monitoring but need to be able to allow machine adaptation to patients needs which may help simplify patient management pathways.

• To further support development in this area of HNIV, research must be conducted in mixed settings in real world patients, involving both higher and lower income countries, with cost-effectiveness built in as part of outcome measures.

Declaration of interest

S Mandal has received consultancy and speaker fees from Philips, grants from Acurable Ltd and Fisher and Paykel Healthcare, and an educational grant to attend a conference by Vivisol. A Saigal has received honoraria for lecturing from Fisher and Paykel Healthcare and received an educational grant toward attendance at a conference from Vivisol. A Shah has received an educational grant toward attendance at a conference from Vivisol. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was not funded.