CPAP vs NIV: Which Is a Better First-Line Treatment For OHS?

Continuous positive airway pressure (CPAP)—rather than noninvasive ventilation (NIV)— should be the first-line treatment for stable ambulatory patients with obesity hypoventilation syndrome (OHS) and coexistent severe obstructive sleep apnea (OSA), according to a panel of experts who performed a new systematic review for the American Thoracic Society’s clinical practice guideline on OHS.

To determine which positive airway pressure (PAP) therapy is more effective for patients with OHS, the international multidisciplinary panel identified studies published from January 1946 to March 2019 in the MEDLINE, the Cochrane Library, and Embase databases that compared NIV with CPAP as initial treatment for OHS. In all, the experts identified 2994 potentially relevant articles, 21 of which were reviewed and 5 of which were selected. 

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The 5 articles that the experts used included 3 randomized trials (1 reported as 2 articles) and an observational study, with sample sizes ranging from 36 to 225 participants.

After conducting the review, the panel determined that there were no differences in mortality, cardiovascular events, or health care resource use between patients with OHS treated with NIV or CPAP. In fact, both PAP therapies had similar effectiveness in improving gas exchange, the need for supplemental oxygen, daytime sleepiness, sleep quality, quality of life, dyspnea, and sleep-disordered breathing. The adherence to both was also similar.

Although the effectiveness of CPAP and NIV was similar, CPAP is more cost-effective and requires fewer resources than NIV. In turn, the panel made the conditional recommendation that CPAP be used instead of NIV as the first-line treatment for stable ambulatory patients with OHS and OSA.

The recommendation was conditional and based on very low-quality evidence, because some outcomes yielded low or very low certainty in estimated effects.

“Given that approximately 70% of patients with OHS have coexistent severe OSA, this recommendation applies to the great majority of patients with stable OHS, but it should not be extrapolated to patients with OHS without severe OSA,” the researchers concluded. “Patients of advanced age, with poor lung function, or with greater or recent acute ventilatory failure may not respond adequately to CPAP.”

—Colleen Murphy

Reference:

Soghier I, Brożek JL, Afshar M, et al. Noninvasive ventilation versus CPAP as initial treatment of obesity hypoventilation syndrome. Ann Am Thorac Soc. 2019;16(10). doi:10.1513/AnnalsATS.201905-380OC.