Lifestyle rehab should go hand in hand with NIV


By Amanda Sheppeard

9 Nov 2017

The use of nocturnal non-invasive ventilation (NIV) may help correct sleep-related breathing abnormalities in patients with obesity hypoventilation syndrome (OHS), but cannot be relied upon to address cardiovascular or metabolic co-morbidities.

Instead, NIV should be a part of an integrated treatment plan that includes lifestyle modification and pulmonary rehabilitation, says a senior respiratory failure expert.

Associate Professor Amanda Piper, from the Royal Prince Alfred Department of Respiratory and Sleep Medicine’s Respiratory Failure Service, and Associate Editor of Respirology, told the limbic that while there was no doubt NIV improved clinical symptoms of OHS and quality of life, clinicians needed to use these to push for better health outcomes.

“Once you pick up the sleep, it’s not just about treating the sleep and the breathing,” she said. “There is no evidence that NIV makes a difference to metabolic and cardiovascular biomarkers. These need to be addressed – just putting patients who are obese and have any respiratory complications on NIV, that’s not enough for them.”

Her comments come with the release of research showing “promising results” for OHS patients who undertook an intensive rehabilitation program in conjunction with NIV.

The research, published in Thorax, reported on a three-month multimodal hybrid inpatient–outpatient motivation, exercise and nutrition rehabilitation programme, in addition to NIV for patients with OHS.

The single-centre randomised controlled trial pilot known as Nutrition and Exercise Rehabilitation in Obesity hypoventilation syndrome (NERO) allocated patients to either standard care or standard care plus rehabilitation.

The primary outcome was percentage weight loss at 12 months with secondary outcomes of weight loss, exercise capacity and health-related quality of life (HRQOL) at the end of the rehabilitation program.

The results showed the rehab, in addition to NIV, resulted in improved weight loss, exercise capacity and QOL at the end of the rehabilitation period. However these effects were not demonstrated at 12 months, in part, due to limited retention of patients.

Professor Piper, who co-authored an editorial in Thorax on the research, said while the 12 month results were disappointing, overall it showed strong promise for future research. In the meantime, she said it supported the use of rehabilitation and exercise for all patients who are prescribed NIV.

“Although very few studies have specifically assessed the impact of NIV on cardiometabolic markers, none have reported any significant change in these parameters from NIV alone,” the editorial said.

“Therefore, these exploratory results suggest that combining NIV and rehabilitation may attenuate cardiometabolic risks in patients with OHS.

Moreover, although the benefits of rehabilitation programme on body weight are likely to be lost by 12 months, significant long-term cardiometabolic improvements may persist due to the reduction in ectopic fat deposition in liver and muscles.

“Thus, in the present study, the long-term aim of the comprehensive rehabilitation programme to reduce body weight could have led to an underestimation of the cardiometabolic benefits of this intervention.”

Professor Piper told the limbic that integrating NIV into a comprehensive treatment plan including lifestyle modification and rehabilitation has proved difficult in practice with barriers such as access to services and the lack of infrastructure.

The practicalities of treating obese patients, some of whom have BMIs of 50 or 60, could also present a ‘logistical nightmare’, especially in rural and remote areas.

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