Nocturnal mechanical ventilation for chronic hypoventilation in patients with neuromuscular and chest wall disorders

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Abstract
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. 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. 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. 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. We identified eight randomised trials. 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. 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. 對於神經肌肉疾病與胸壁疾病病人有慢性換氣不足情況使用夜間機械換氣 很多神經肌肉疾病與胸壁疾病會產生慢性肺泡換氣不足，有越來越多治療採用長期夜間機械換氣 目的是檢視夜間機械換氣治療對於神經肌肉疾病與胸壁疾病病人，減輕換氣不足症狀以及延長存活的效果 我們搜尋了考科藍神經肌肉疾病組試驗註冊目錄、MEDLINE(1966年1月至2006年6月)、EMBASE(1980年1月至2006年6月)中隨機試驗並連絡參與試驗的作者們及這個領域的其他專家們 我們搜尋了準隨機或隨機試驗，其中有各個年紀和疾病嚴重度的神經肌肉疾病與胸壁疾病相關之慢性換氣不足的參與者，接受任何治療及任何模式的機械換氣，主要結果為測量短期和長期時，換氣不足臨床症狀改善的程度，次要結果包括預期之外的住院、一年死亡率、長短期的白天高碳酸血症改善、肺功能及睡眠呼吸疾病的改善。 我們確認出8個隨機試驗 這8篇合格的試驗包括了共144位參與者，只有一篇10位參與者的試驗，計算了夜間機械換氣後短期評估‘換氣不足臨床症狀無改善‘的relative risk，且無顯著差異為0.09(95% CI 0.01 to 1.31)。夜間換氣後短期評估‘日間高碳酸血症無改善‘的relative risk有意義，且結果偏向治療優勢0.37(95% CI 0.20 to 0.65)。夜間平均血氧濃度的平均差異為5.45%(95% CI 1.47 to 9.44)，以夜間機械換氣治療的進步較多。大多在長期的評估夜間機械換氣與無換氣治療並無差異，不過根據三篇研究，夜間換氣後的預估死亡率有下降0.62 (95% CI 0.42 to 0.91)。各個試驗之間可能因為研究族群的不同而導致結果多樣性，大多試驗並無評估次要結果，有二篇crossover試驗關於體積循環及壓力循環換氣，在日間高碳酸血症以及睡眠研究參數沒有證據顯示出差異。關於侵入性及非侵入性機械換氣的比較或者漸歇性正壓及負壓換氣之比較尚無文獻。...

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