Critically appraised paper: In people with chronic obstructive pulmonary disease, initiation of nocturnal non-invasive ventilation at home is non-inferior to initiation during a hospital admission [commentary]

Commentary

Even before the COVID-19 pandemic gave rise to social distancing and shelter-in-place orders, many older people preferred to receive their healthcare at home.¹ Such services are highly relevant for people with chronic obstructive pulmonary disease, in whom disabling symptoms and travel burden are known barriers to accessing healthcare.² Home-based models are increasingly attractive as an alternative to inpatient admissions, which in chronic obstructive pulmonary disease are the primary contributors to healthcare costs.³

Duiverman et al tested whether initiation of high-intensity non-invasive ventilation at home, including remote adjustment of ventilator settings, was non-inferior to in-hospital initiation for patients with chronic obstructive pulmonary disease and chronic hypercapnic respiratory failure. The between-group difference for the primary outcome (change in daytime partial pressure of carbon dioxide in arterial blood at 6 months) was not clinically significant, with a 95% confidence interval that excluded the non-inferiority margin of 3 mmHg. Improvements in health-related quality of life and symptoms were similar across groups. The cost reduction was considerable (56% lower at home); however, the applicability of this finding will vary across health systems. Hospital initiation of high-intensity non-invasive ventilation required a median of 7.5 inpatient days, which was a major driver of the cost difference. This may not reflect practice in other settings with shorter length of stay, or outpatient-based non-invasive ventilation initiation.⁴

This study provides confidence that home initiation of non-invasive ventilation is clinically efficacious in severe chronic obstructive pulmonary disease. Home non-invasive ventilation initiation required at least two home visits from a specialist nurse, plus additional visits when technical problems were encountered. Eligible patients were those with sufficient social support to manage home initiation of non-invasive ventilation, which could exclude an important minority of patients who live alone or have no caregiver.⁵