Nocturnal mechanical ventilation for chronic hypoventilation in patients with neuromuscular and chest wall disorders.
BACKGROUND
Chronic alveolar hypoventilation is a common complication of many neuromuscular and chest wall disorders. Long-term nocturnal mechanical ventilation is increasingly used to treat it.


OBJECTIVE
To examine the efficacy of nocturnal mechanical ventilation in relieving hypoventilation related symptoms and in prolonging survival in people with neuromuscular or chest wall disorders.


METHODS
We searched the Cochrane Neuromuscular Disease Group Trials Register, MEDLINE (from January 1966 to June 2006), and EMBASE (from January 1980 to June 2006) for randomised trials and contacted authors of trials and other experts in the field.


METHODS
We searched for quasi-randomised or randomised controlled trials of participants with neuromuscular or chest wall disorder-related stable chronic hypoventilation of all ages and all degrees of severity, receiving any type and any mode of nocturnal mechanical ventilation. The primary outcome measure was short-term and long-term reversal of hypoventilation related clinical symptoms and secondary outcomes were unplanned hospital admission, one year mortality, short-term and long-term reversal of daytime hypercapnia, improvement of lung function and sleep breathing disorders.


METHODS
We identified eight randomised trials.


RESULTS
The eight eligible trials included a total of 144 participants. The relative risk of 'no improvement of hypoventilation related clinical symptoms' in the short-term following nocturnal mechanical ventilation was available in only one trial with 10 participants and was not significant, 0.09 (95% confidence interval (CI) 0.01 to 1.31). The relative risk of 'no reversal of daytime hypercapnia' in the short-term following nocturnal ventilation was significant and favoured treatment, 0.37 (95% CI 0.20 to 0.65). The weighted mean difference of nocturnal mean oxygen saturation was 5.45% (95% CI 1.47 to 9.44) more improvement in participants treated with nocturnal mechanical ventilation. For most of the outcome measures there was no significant long-term difference between nocturnal mechanical ventilation and no ventilation. However, the estimated risk of death based on three studies was reduced following nocturnal ventilation, 0.62 (95% CI 0.42 to 0.91). There was considerable and significant heterogeneity between the trials possibly related to differences between the study populations. Most of the secondary outcomes were not assessed in the eligible trials. Data from two crossover trials suggested no evidence for a difference in reversal of daytime hypercapnia and sleep study parameters between volume-cycled and pressure-cycled ventilation. No data could be summarised for the comparisons between invasive and non-invasive mechanical ventilation or between intermittent positive pressure and negative pressure ventilation.


CONCLUSIONS
Current evidence about the therapeutic benefit of mechanical ventilation is weak, but consistent, suggesting alleviation of the symptoms of chronic hypoventilation in the short-term. In three small studies survival was prolonged mainly in participants with motor neuron diseases. With the exception of motor neuron disease, further larger randomised trials are needed to confirm long-term beneficial effects of nocturnal mechanical ventilation on quality of life, morbidity and mortality, to assess its cost-benefit ratio in neuromuscular and chest wall diseases and to compare the different types and modes of ventilation.
Annane
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Hôpital Raymond Poincaré, Assistance Publique - Hôpitaux de Paris, Critical Care Department, 104. Boulevard Raymond Poincaré, Garches, Ile de France, France, 92380. djillali.annane@rpc.ap-hop-paris.fr
Orlikowski
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D
Chevret
S
S
Chevrolet
J C
JC
Raphaël
J C
JC
D002908:Chronic Disease; D006801:Humans; D007040:Hypoventilation / Q000209:etiology / Q000628:therapy*; D009468:Neuromuscular Diseases / Q000150:complications*; D016032:Randomized Controlled Trials as Topic; D012121:Respiration, Artificial; D012890:Sleep; D035441:Thoracic Wall / Q000002:abnormalities*