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

Abstract

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 to waiting for an outpatient evaluation (i.e. outpatient sleep study and outpatient PAP titration). An international, multi-disciplinary 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 (GRADE) was used to summarize evidence and appraise quality. The literature search identified 2,994 articles. There were no randomized trials. Ten studies met a priori study selection criteria, including two non-randomized comparative studies and eight non-randomized non-comparative studies. Individual patient data on hospitalized patients who survived to hospital discharge was 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 non-invasive ventilation (NIV) was prescribed in 91.5% of patients discharged on PAP and the remainder received empiric continuous PAP (CPAP). Discharge with PAP reduced mortality at 3-months (RR 0.12, 95% CI 0.05-0.30, RD -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.