Home-based initiation of NIV in stable OHS is safe and effective

The increasing number of patients with obesity hypoventilation syndrome (OHS) can be safely introduced to home non-invasive ventilation (NIV) therapy through an outpatient model.

According to an international trial, the model is also cost effective and relevant from infection control and resource allocation perspectives during the recovery stage of the COVID-19 pandemic.

The trial, published in Thorax (link), randomised 82 clinically stable OHS patients from six centres in the UK and France to either outpatient or inpatient NIV set-up.

Outpatient setup was conducted by an experienced NIV clinician using a predefined protocol and an autotitrating NIV mode (AVAPS-AE). Inpatients underwent overnight respiratory polygraphy, including transcutaneous carbon dioxide and titration of NIV until adequate control of sleep-disordered breathing (SDB) or maximal tolerated pressures were reached.

The study demonstrated improvement in PaCO2 in both groups.

“There was no difference in clinically relevant secondary outcomes between inpatient and outpatient setup at 3 months, including change in dyspnoea, lung function, exercise capacity, body composition and anthropometrics.”

As well, there were similar quality of life improvements at month three in both groups when measured by EQ-5D-5L and the Severe Respiratory Insufficiency (SRI) questionnaire.

“Total per patient cost (fixed, OHS-related and non-OHS-related healthcare utilisation) for inpatient setup (£2962±£580) were similar to outpatient cost (£3169±£525) with no significant difference in cost of NIV setup between groups (£188.20, 95% CI £−61.61 to £438.01),” it said.

The study also found no difference between the groups in terms of SDB management, subjective and objective sleep quality, NIV adherence and NIV settings at 3 months.

The investigators concluded there was no difference in medium-term cost-effectiveness between home NIV setup employing an outpatient pathway and an autotitrating NIV device, compared with inpatient NIV setup incorporating clinician-led attended overnight titration.

“These data provide strong evidence to underpin the planning of home NIV provision for obese patients with chronic respiratory failure. Development and delivery of chronic respiratory failure pathways to manage the increasing number of obese patients requiring NIV by employing autotitrating NIV devices in an outpatient setting which will reduce the demand on inpatient capacity.”

They also noted that NIV is an aerosol generating procedure which may be more safely and easily contained in single room, well-ventilated outpatient settings than via inpatient delivery on open wards.

Australian perspective

An editorial (link) in the journal said home-based implementation of NIV for ventilatory failure is also increasingly being shown to be safe and effective compared with inpatient implementation in COPD, neuromuscular and chest wall disease.

The authors, Associate Professor Mark Howard and Dr Anne Ridgers from Austin Health, said healthcare cost savings appear to be predominantly driven by the high cost of multiday admission to intensive care or respiratory high-dependency beds to initiate NIV in inpatient models.

“In addition to cost savings, home implementation reduces the potential risk of infection transmission given the aerosol-generating properties of NIV and enhances capacity for high-dependency acute hospital beds which are critical in the current environment.”

“In some studies, home implementation has also reduced NIV implementation waiting time in a vulnerable population that frequently has a high level of disability and related support requirements.”

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