title: The effect of domiciliary noninvasive ventilation on clinical outcomes in stable and recently hospitalized patients with COPD: a systematic review and meta-analysis.
abstract: BACKGROUND
  Noninvasive ventilation (NIV) improves survival among patients with hypercapnic respiratory failure in hospital, but evidence for its use in domiciliary settings is limited. A patient's underlying risk of having an exacerbation may affect any potential benefit that can be gained from domiciliary NIV. This is the first comprehensive systematic review to stratify patients based on a proxy for exacerbation risk: patients in a stable state and those immediately post-exacerbation hospitalization.
  
  
  METHODS
  A systematic review of nonrandomized and randomized controlled trials (RCTs) was undertaken in order to compare the relative effectiveness of different types of domiciliary NIV and usual care on hospital admissions, mortality, and health-related quality of life. Standard systematic review methods were used for identifying studies (until September 2014), quality appraisal, and synthesis. Data were presented in forest plots and pooled where appropriate using random-effects meta-analysis.
  
  
  RESULTS
  Thirty-one studies were included. For stable patients, there was no evidence of a survival benefit from NIV (relative risk [RR] 0.88 [0.55, 1.43],I2=60.4%, n=7 RCTs), but there was a possible trend toward fewer hospitalizations (weighted mean difference -0.46 [-1.02, 0.09],I2=59.2%, n=5 RCTs) and improved health-related quality of life. For posthospital patients, survival benefit could not be demonstrated within the three RCTs (RR 0.89 [0.53, 1.49],I2=25.1%), although there was evidence of benefit from four non-RCTs (RR 0.45 [0.32, 0.65],I2=0%). Effects on hospitalizations were inconsistent. Post hoc analyses suggested that NIV-related improvements in hypercapnia were associated with reduced hospital admissions across both populations. Little data were available comparing different types of NIV.
  
  
  CONCLUSIONS
  The effectiveness of domiciliary NIV remains uncertain; however, some patients may benefit. Further research is required to identify these patients and to explore the relevance of improvements in hypercapnia in influencing clinical outcomes. Optimum time points for commencing domiciliary NIV and equipment settings need to be established.
authors.affiliation: Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston.
authors.forename: Janine
authors.initials: J
authors.lastname: Dretzke
authors.affiliation: Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston.
authors.forename: David
authors.initials: D
authors.lastname: Moore
authors.affiliation: Heart of England NHS Foundation Trust, Heartlands Hospital.
authors.forename: Chirag
authors.initials: C
authors.lastname: Dave
authors.affiliation: Heart of England NHS Foundation Trust, Heartlands Hospital.
authors.forename: Rahul
authors.initials: R
authors.lastname: Mukherjee
authors.affiliation: Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston.
authors.forename: Malcolm J
authors.initials: MJ
authors.lastname: Price
authors.affiliation: Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston.
authors.forename: Sue
authors.initials: S
authors.lastname: Bayliss
authors.affiliation: Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston.
authors.forename: Xiaoying
authors.initials: X
authors.lastname: Wu
authors.affiliation: Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Edgbaston.
authors.forename: Rachel E
authors.initials: RE
authors.lastname: Jordan
authors.affiliation: Heart of England NHS Foundation Trust, Heartlands Hospital; Queen Elizabeth Hospital Research Laboratories, University of Birmingham, Edgbaston, Birmingham, UK.
authors.forename: Alice M
authors.initials: AM
authors.lastname: Turner
mesh_terms: D018450:Disease Progression; D006699:Home Care Services; D006760:Hospitalization; D006801:Humans; D006935:Hypercapnia / Q000503:physiopathology / Q000628:therapy; D008168:Lung / Q000503:physiopathology*; D063087:Noninvasive Ventilation / Q000009:adverse effects / Q000379:methods*; D010359:Patient Readmission; D029424:Pulmonary Disease, Chronic Obstructive / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*; D011788:Quality of Life; D012307:Risk Factors; D016896:Treatment Outcome
keywords: COPD; domiciliary; hospitalization; meta-analysis; noninvasive ventilation; systematic review