Non‐invasive ventilation for obese patients with chronic respiratory failure: Are two pressures always better than one?

Abstract

Obesity‐related respiratory failure is increasingly common but remains under‐diagnosed and under‐treated. There are several clinical phenotypes reported, including severe obstructive sleep apnoea (OSA), isolated nocturnal hypoventilation with or without severe OSA and OSA complicating chronic obstructive pulmonary disease (COPD). The presence of hypercapnic respiratory failure is associated with poor clinical outcomes in each of these groups. While weight loss is a core aim of management, this is often unachievable, and treatment of sleep‐disordered breathing with positive airway pressure (PAP) therapy is the mainstay of clinical practice. Although there are few long‐term clinical efficacy trials, the lack of equipoise would prevent the utilization of an untreated control group. The current data support the use of PAP therapy to improve respiratory failure and is associated with improvements in health‐related quality of life, reduced healthcare utilization and reduced mortality. Both continuous PAP (CPAP) and non‐invasive ventilation (NIV) appear safe and effective in patients with obesity‐related respiratory failure and OSA, with or without COPD, and the current evidence would not support a single therapy choice in all patients. There are no studies of CPAP in patients with isolated nocturnal hypoventilation, and NIV would be the current recommendation in this patient group. Whichever starting therapy is used, titration should be performed to correct sleep‐disordered breathing and reverse chronic respiratory failure, with consideration of step‐down of the treatment based on a clinical re‐evaluation. In contrast, failure to reach physiological and clinical treatment targets should lead to the consideration of treatment escalation.

Home mechanical ventilation: back to basics

“…A recent analysis of national health insurance data did not find that HMV was used to treat obesity-related respiratory failure in South Korea. However, with rising levels of obesity in South Korea, it is important for clinicians to be aware of obesity hypoventilation syndrome (defined as a body mass index > 30 kg/m 2 , daytime hypercapnia, and the presence of sleep-disordered breathing) as a potential cause of chronic respiratory failure for which the treatment is either nocturnal continuous positive airway pressure (CPAP) or NIV [ 22 ].…”

Treatment of COVID-19 Acute Respiratory Distress Syndrome With a Tabletop Noninvasive Ventilation Device in a Respiratory Intermediate Care Unit

“…Although HFNO consumes high volumes of oxygen, which is both expensive and precious, providing NIV through a ventilator is both expensive and requires high levels of expertise. Noninvasive ventilation has been extensively recommended for the management of respiratory failure, predominantly caused by chronic obstructive pulmonary disease [8][9][10] and obesity, 11 both in hospitals and homes because tabletop NIV is a suitable option for both. Because it can provide a positive endexpiratory pressure for the treatment of obstructive sleep apnea and pressure support as required for the treatment of chronic obstructive pulmonary disease or obesity hypoventilation syndrome, its use can be extended beyond to treat other causes of type 1 and 2 respiratory failure.…”

Positive airway pressure in obesity hypoventilation syndrome: is it worth it?

“…Over the past decade, increasing attention has been paid to the evaluation and management of obesity hypoventilation syndrome (OHS) 1. This disorder is characterised by daytime hypercapnia and three main phenotypes of sleep disordered breathing, including severe obstructive sleep apnoea (OSA), combined OSA and OHS and isolated OHS 2. Rising rates of global obesity along with a greater awareness of the significant health and social costs of this disorder have been driving factors fuelling interest in how best to manage those with OHS.…”