Babak Mokhlesi1, Juan Fernando Masa2,3, Majid Afshar4, Virginia Almadana Pacheco5, David J Berlowitz6, Jean-Christian Borel7, Stephan Budweiser8, Andres Carrillo9, Olalla Castro-Añón10, Miquel Ferrer3,11, Frédéric Gagnadoux12,13, Rafael Golpe10, Nicholas Hart14, Mark E Howard6, Patrick B Murphy14, Andreas Palm15, Luis A Perez de Llano10, Amanda J Piper16,17, Jean Louis Pépin7, Pascaline Priou12,13, Jesús F Sánchez-Gómez5, Israa Soghier18, Maximiliano Tamae Kakazu19, Kevin C Wilson20,21. 1. Department of Medicine, University of Chicago, Chicago, Illinois. 2. Respiratory Department, San Pedro de Alcántara Hospital, Cáceres, Spain. 3. Centro de Investigación Biomédica en Red Enfermedades Respiratorias, Madrid, Spain. 4. Department of Health Informatics and Data Science, Loyola University, Chicago, Illinois. 5. Clinical Unit of Pneumology, Hospital Universitario Virgen Macarena, Seville, Spain. 6. Institute for Breathing and Sleep, Austin Health, Heidelberg, Victoria, Australia. 7. HP2 Laboratory, INSERM U1042, University of Grenoble Alpes, Grenoble, France. 8. Division of Pulmonary and Respiratory Medicine, RoMed Clinical Centre, Rosenheim, Germany. 9. Intensive Care Unit, Hospital J.M. Morales Meseguer, Murcia, Spain. 10. Pneumology Service, Lucus Augusti University Hospital, Galicia, Spain. 11. Department of Pneumology, Hospital Clinic of Barcelona, University of Barcelona, Barcelona, Spain. 12. Department of Respiratory Diseases, and. 13. INSERM U1063, Angers University Hospital, Angers, France. 14. Lane Fox Respiratory Service, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom. 15. Department of Medical Sciences, Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden. 16. Royal Prince Alfred Hospital, and. 17. University of Sydney, Camperdown, New South Wales, Australia. 18. Department of Medicine, Albert Einstein College of Medicine, Bronx, New York. 19. Division of Pulmonary and Critical Care Medicine Spectrum Health, Michigan State University College of Human Medicine, Grand Rapids, Michigan. 20. Department of Medicine, Boston University School of Medicine, Boston, Massachusetts; and. 21. American Thoracic Society, New York, New York.
Abstract
Rationale: 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 with waiting for an outpatient evaluation (i.e., outpatient sleep study and outpatient PAP titration). Objectives: An international, multidisciplinary 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. Methods: 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 was used to summarize evidence and appraise quality. Results: The literature search identified 2,994 articles. There were no randomized trials. Ten studies met a priori study selection criteria, including two nonrandomized comparative studies and eight nonrandomized noncomparative studies. Individual patient data on hospitalized patients who survived to hospital discharge were 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 noninvasive ventilation was prescribed in 91.5% of patients discharged on PAP, and the remainder received empiric continuous PAP. Discharge with PAP reduced mortality at 3 months (relative risk 0.12, 95% confidence interval 0.05-0.30, risk difference -14.5%). Certainty in the estimated effects was very low.Conclusions: 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.
Rationale: 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 with waiting for an outpatient evaluation (i.e., outpatient sleep study and outpatient PAP titration). Objectives: An international, multidisciplinary 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. Methods: 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 was used to summarize evidence and appraise quality. Results: The literature search identified 2,994 articles. There were no randomized trials. Ten studies met a priori study selection criteria, including two nonrandomized comparative studies and eight nonrandomized noncomparative studies. Individual patient data on hospitalized patients who survived to hospital discharge were 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 noninvasive ventilation was prescribed in 91.5% of patients discharged on PAP, and the remainder received empiric continuous PAP. Discharge with PAP reduced mortality at 3 months (relative risk 0.12, 95% confidence interval 0.05-0.30, risk difference -14.5%). Certainty in the estimated effects was very low.Conclusions: 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.
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