Positive airway pressure therapy variants for OSAHS, OHS and COPD–OSAHS overlap syndrome

National Guideline Centre (UK)

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Positive airway pressure therapy variants for OSAHS, OHS and COPD–OSAHS overlap syndrome

Obstructive sleep apnoea/hypopnoea syndrome and obesity hypoventilation syndrome in over 16s

Evidence review F

NICE Guideline, No. 202

National Guideline Centre (UK).

London: National Institute for Health and Care Excellence (NICE); 2021 Aug.

ISBN-13: 978-1-4731-4229-9

1. Positive airway pressure therapy variants

1.1. Review question: What is the comparative clinical and cost effectiveness of different types of positive airway pressure devices (for example, fixed-pressure CPAP, variable-pressure CPAP, bi-level positive airway pressure or other modes of non-invasive ventilation) for managing obstructive sleep apnoea/hypopnoea syndrome (OSAHS), obesity hypoventilation syndrome (OHS) and COPD-OSAHS overlap syndrome?

1.2. Introduction

People with significant sleep disordered breathing who suffer from repeated partial or full airway obstruction are often treated with devices that deliver positive airway pressure. This pressure is sufficient to force the relaxed soft tissues and muscles apart, and in doing so splint open the airway. There are a number of benefits, not least that breathing can resume as normal and can greatly improve the quality of sleep. The impact of this is the reduction of excessive sleepiness during waking hours, as well as other health benefits for example, reduced risk of cardiovascular disease and stroke. Some people with disorders such as obesity hypoventilation syndrome or Chronic Obstructive Pulmonary Disease (COPD) alongside Obstructive sleep Apnoea/Hypopnea (COPD-OSAHS overlap syndrome) may also benefit from a device that delivers positive pressure.

Positive airway pressure treatment can be delivered via a number of devices and through the use of fixed, auto or bi-level pressure. The clinical and cost effectiveness of these different forms of positive pressure treatment are compared in this review.

1.3. PICO table

For full details see the review protocol in appendix A.

Table 1

PICO characteristics of review question.

1.4. Clinical evidence

1.4.1. Included studies

OSAHS population

One Cochrane review¹¹⁰ including 48 RCTs was included in the review. The review included randomised parallel group and crossover trials in people with OSAHS. Studies that compared auto-titrating CPAP (auto-CPAP), or non-invasive ventilation, or the addition of heated humidification to CPAP with fixed level CPAP alone were included. We have not included all studies from the Cochrane review, as the committee agreed that some of the interventions/comparisons were not relevant.

Thirty six studies compared auto-CPAP with fixed level CPAP:¹⁸^, ²³^, ³⁴^, ³⁶^, ⁵⁰^, ⁵¹^, ⁶²^, ⁶⁶^, ⁷⁰^, ⁹⁸^, ¹⁰²^, ¹⁰⁵^, ¹⁰⁷^, ¹¹³^, ¹³²^, ¹⁴⁷^, ¹⁵⁰^, ¹⁵³^, ¹⁸⁵^, ¹⁸⁸^, ¹⁸⁹^, ¹⁹³^, ¹⁹⁹^, ²¹⁴^, ²²¹^, ²²⁴^, ²²⁵^, ²²⁸^, ²³⁷^–²³⁹^, ²⁵³^, ²⁵⁴^, ²⁵⁷^, ²⁶⁰^, ²⁶⁵

Six studies compared bi-level PAP machines with fixed pressure CPAP.⁷⁴^, ⁷⁷^, ⁸¹^, ¹³⁷^, ¹⁶¹^, ²¹⁹

Six studies assessed the addition of humidification to fixed pressure CPAP.⁸⁴^, ¹⁸⁰^, ²³⁰^, ²³¹^, ²⁴⁶^, ²⁶⁷

Studies mainly recruited men who were recently diagnosed with OSAHS. The majority of study participants had not used CPAP previously. They had excessive daytime sleepiness (average ESS at baseline was 13), majority of the studies had people with severe sleep disturbance (AHI range 14.7 to 59.7) and average Body Mass Index of about 35kg/m².

The duration of included studies ranged from 2 weeks to 2 years. All evidence was in people with moderate to severe sleep apnoea (AHI >/= 15 but <30 moderate and AHI >/= 30 severe); however the majority of the studies were in people with severe sleep apnoea.

The use of standard CPAP titration protocols was common across the studies. Most were conducted over one or two nights. Extended adaptation protocols which increased the exposure of participants to CPAP devices were undertaken in two studies in order to establish optimal CPAP pressure and comfort prior to formal initiation of treatment (e.g. Bloch 2018; Senn 2003).

Two instruments validated in sleep apnoea research were used for measuring quality of life (SAQLI and FOSQ) either in combination with the Short-form 36 (SF-36) or on their own. For some studies only the SF-36 was used.

There was considerable variation in the methods used to measure tolerability or adverse events. Studies used diary records and interviews to capture effects, and both dichotomous data (did or did not experience the event) or scales to rate problems with mask leak, pressure tolerance, dry mouth and nasal symptoms.

The data reported in the summary of studies, evidence tables, forest plots and exclusion list in this review is from the Cochrane review. The GRADE quality assessments were done by the NGC.

OHS population

Nine studies were included in the review;²⁵^, ⁹⁵^, ¹³⁵^, ¹³⁷^, ¹³⁹^, ¹⁴²^, ¹⁶⁸^, ²⁰⁶^, ²⁴⁹ these are summarised in Table 2 below. Evidence from these studies is summarised in the clinical evidence summary below (Table 4).

Three studies compared non-invasive ventilation (NIV) with lifestyle advice only, 3 studies compared non-invasive ventilation with CPAP, 1 study compared non-invasive ventilation, CPAP and lifestyle advice and 2 studies compared volume assured non-invasive ventilation with fixed non-invasive ventilation.

The data reported in the summary of studies and forest plots is from an unpublished Cochrane review.⁴⁰ The GRADE quality assessments, evidence tables and exclusion list were done by the NGC. See also the study selection flow chart in appendix C, study evidence tables in appendix D, forest plots in appendix E and GRADE tables in appendix H.

COPD-OSAHS overlap syndrome

There was no evidence available people with COPD-OSAHS overlap syndrome.

1.4.2. Excluded studies

See the excluded studies list in appendix I.

1.4.3. Summary of clinical studies included in the evidence review -OSAHS

Table 2

Summary of Cochrane review in the evidence review.

1.4.4. Summary of clinical studies included in the evidence review –OHS population

Table 3

Summary of studies included in the evidence review.

See appendix D for full evidence tables.

1.4.5. Quality assessment of clinical studies included in the evidence review –OSAHS population

Table 4

Clinical evidence summary: Auto-CPAP versus fixed level CPAP for improving usage of continuous positive airway pressure machines in adults with OSAHS –severe OSAHS.

Table 5

Clinical evidence summary: Non-invasive ventilation versus fixed level CPAP for improving usage of continuous positive airway pressure machines in adults with OSAHS-severe OSAHS.

Table 5

Clinical evidence summary: Heated humidification + fixed level CPAP versus fixed level CPAP alone for improving usage of continuous positive airway pressure machines in adults with obstructive sleep apnoea- severe OSAHS.

1.4.6. Quality assessment of clinical studies included in the evidence review – OHS population

Table 6

Clinical evidence summary: Fixed non-invasive ventilation (NIV) vs Volume assured non-invasive ventilation (NIV).

Table 7

Clinical evidence summary: Non-invasive ventilation (NIV) vs lifestyle.

Table 8

Clinical evidence summary: Non-invasive ventilation (NIV) vs CPAP.

Table 9

Clinical evidence summary: CPAP vs lifestyle.

See appendix F for full GRADE tables.

Narrative results

Data on tolerability outcomes were measured and reported inconsistently across the studies. Data have been presented a narratively for studies where could not not be analysed (data were presented graphically or data could not be adjusted adequately for the crossover design). Narrative data was considered alongside the GRADE evidence by the committee when making recommendations. The overall study quality was taken into account as GRADE analysis for each outcome could not be performed.

Auto CPAP vs fixed CPAP

Nasal blockage (very low quality)

Four participants in Sériès 1997 suffered nasal blockage (two from auto-CPAP1 group, one from auto-CPAP2, and one from fixed CPAP), which resolved with the use of a heated humidifier. Nolan 2007 presented bar charts of those experiencing blocked or runny nose during both arms of treatment (just over 40% in those treated with auto-CPAP and just over 30% in those with fixed pressure CPAP based on visual inspection, N = 26).

Nussbaumer 2006 reported similar scores between treatment arms by participants who rated symptoms on a VAS (N = 38).

Tolerance of treatment pressure (very low quality)

Massie 2003 reported a significant difference between auto and fixed CPAP in favour of the automatic pressure mode on feeling discomfort from pressure and experiencing less trouble getting to sleep (all values P < 0.006). Randerath 2001 reported no significant differences between the two groups who were treated with both auto and fixed CPAP (no numerical values presented). d’Ortho 2000 reported little difference on an un-validated questionnaire measuring tolerance of treatment pressure between auto-CPAP and fixed CPAP (N = 25). In Nussbaumer 2006 participant-rated tolerance of treatment pressure was better in the auto-CPAP arm than during fixed pressure CPAP treatment.

Mask leak (very low quality)

Nolan 2007 presented data that indicated slightly fewer participants experiencing leak with auto-CPAP (just over 20% versus just under 25% based on visual inspection).

Teschler 2000 reported no significant difference in mask leak between fixed CPAP (13% mask on time with leak of 0.4 Ls-1) and auto-CPAP (10% mask on time with leak of 0.4 Ls-1). Hukins 2004, Damjanovic 2009, Galetke 2008 and West 2006 reported slightly fewer leaks as either number of leaks per person, leakage time or pressure leaked per second with auto-CPAP compared with CPAP. Nussbaumer 2006 found that mask leaks were perceived to be less problematic on auto-CPAP than on fixed pressure CPAP.

NIV vs fixed CPAP

Tolerability outcomes (very low quality)

Reeves-Hoché 1995 reported five withdrawals due to either mask discomfort (n = 2) or therapy intolerance (n = 3). All were from the CPAP group. No withdrawals due to mask discomfort or therapy intolerance occurred from the bi-level PAP group. Twenty participants complained of nasal dryness (no distribution between the two groups reported). Three participants complained of rhinorrhoea and 15 participants complained of nasal bridge pressure (no distribution reported between the two groups).

Gay 2003 reported that telephone contact did not identify any complications that necessitated further interventions. Muir 1998 did not report data in terms of specific adverse effects. No difference in the rate of adverse effects was reported. Gulati 2015 used a global treatment comfort score on a 0-100 VAS but there was insufficient evidence to determine the effect (Bi-PAP: 69 versus fixed CPAP 60, P = 0.16).

1.5. Economic evidence

1.5.1. Included studies

Two health economic study were included in this review, one for OSAHS²³ and the other for OHS¹⁴¹. This is summarised in the health economic evidence profile below (Table 10) and the health economic evidence table in appendix H.

1.5.2. Excluded studies

No health economic studies that were relevant to this question were excluded due to assessment of limited applicability or methodological limitations.

See also the health economic study selection flow chart in appendix G.

1.5.3. Summary of studies included in the economic evidence review

Table 10

Health economic evidence profile: Auto-CPAP versus fixed level CPAP.

Table 11

Health economic evidence profile: Non-invasive ventilation versus CPAP.

1.5.4. Unit costs

Unit costs were presented to the guideline committee.

Table 12

Unit costs of positive airway pressure devices with and without humidification.

Table 13

Unit cost of non-invasive ventilation devices for obesity hypoventilation syndrome.

1.5.5. Health economic modelling

This analysis was conducted as a sub-analysis of the main guideline model, which covered the diagnostic and treatment pathway for people suspected of having OSAHS (See Economic analysis report).

1.5.5.1. Strategies compared

The cost of auto-CPAP devices are more expensive than the fixed level devices. However, this cost will be at least partially offset by reduced staff time required in re-titrating patients. Since the cost of re-titration can be reduced in the presence of telemonitoring, we considered costs in the presence and absence of telemonitoring.

1.5.5.2. Methods and data sources (Summary)

Health outcomes
- We assumed no difference in patient outcomes between strategies.
Costs
- Set up costs, 3 month review and annual review costs were assumed to be the same for each strategy and only device costs, telemonitoring and retitration costs differ between strategies
- The cost of the CPAP devices and consumables were extracted from the NHS Supply catalogue (and VAT removed). The unweighted mean of different devices (excluding VAT) was used in the model base case - £207 for fixed-CPAP and £320 for auto-CPAP. Higher and lower costs were used in a sensitivity analysis.
- The device costs were annuitized using a discount rate of 3.5% and assuming the equipment is replaced after 7 years.
- Telemonitoring costs were from ResMed (£45 for one year or £150 for 5 years).
- Education and set up was costed as a respiratory consultant-led outpatient consultation and follow-up was a non-consultant-led outpatient consultation. The unit costs were ‘NHS costs’.
Re—titration
- Re-titration using telemonitoring was assumed to take up 20 minutes of a physiologist’s time (60 minutes in a sensitivity analysis).
- Re-titration using auto-titration was assumed to require an auto-CPAP machine over 2 nights and analysis of the results was assumed to take 45 minutes of a physiologist’s time (75 minutes in a sensitivity analysis) and 10 minutes of a medical consultant.
- The unit cost of staff time used in re-titration were standard NHS costs from the PSSRU (£47 per hour for a band 6 physiologist and £109 per hour for a medical consultant)
- It was assumed that 18% of patients using fixed-CPAP would require re-titration – based on the number of patients having an unplanned contact in one of the included trials.²³ This was increased to 30% in a sensitivity analysis.
Lifetime costs
- The lifetime costs were calculated from the main guideline model and include the cost of RTAs and the health care costs associated with treating cardiovascular events. However, these costs were assumed not to vary between strategies. The difference in lifetime cost between strategies is attributable to the differences in device, telemonitoring and retitration costs.
- The lifetime costs were based on a cohort of men aged 50. This was calculated separately for men with mild OSAHS and for men with moderate OSAHS. The only difference was that dropout from treatment was greater than for the men with mild OSAHS.

The resulting cost per year of treatment is shown in Table 14.

Table 14

Cost (£) of each strategy per year of treatment.

Results

The lowest cost strategy was Fixed-level CPAP with auto-titration followed by Fixed-level CPAP with telemonitoring for one year and then by auto-CPAP – see Table 15. The ranking was the same across all the sensitivity analyses.

Table 15

Lifetime mean cost (£) per patient of each strategy.

This analysis was assessed to be partially applicable because it does not include QALYs with potentially serious limitations, since resource use was based on expert opinion.

1.6. Economic evidence statements

One cost-utility comparison based on a published cost consequences analysis found that:
- Fixed-level CPAP dominated auto-CPAP for adults with OSAHS (based on OSAHS costs)
- Fixed-level CPAP was cost effective compared with auto-CPAP for adults with OSAHS (£2000 per QALY gained) (based on all health care costs)
This analysis was assessed to be partially applicable with potentially serious limitations.
One cost analysis found that CPAP was cost saving compared to non-invasive ventilation for people with obesity hypoventilation syndrome.
This analysis was assessed to be partially applicable with minor limitations.
One original cost comparison found that:
- Fixed-level CPAP (using auto-CPAP just for re-titration) was the lowest cost strategy
- Fixed-level CPAP (with telemonitoring) was less costly than auto-CPAP with telemonitoring
- Fixed-level CPAP (with telemonitoring for 1 year) was less costly than auto-CPAP without telemonitoring
- Fixed-level CPAP (with telemonitoring) was more costly than auto-CPAP without telemonitoring
This analysis was assessed to be partially applicable with potentially serious limitations.

1.7. The committee’s discussion of the evidence

1.7.1. Interpreting the evidence

1.7.1.1. The outcomes that matter most

The committee considered the outcome of health-related quality of life as critical outcome for decision making. Other important outcomes included sleepiness scores (e.g. Epworth), Apnoea-Hypopnoea index, Oxygen desaturation index, hours of use, minor adverse effects of treatment, tolerability of the treatment (such as dry mouth, stuffy nose, mask intolerance), treatment pressure, expression of preference. The committee were also interested in the impact on co-existing conditions such as HbA1c for diabetes, cardiovascular events and systolic blood pressure for hypertension.

No evidence was identified for impact on cardiovascular events in the OSAHS population.

No evidence was identified for the outcomes of adverse effects of treatments, tolerability of the treatment, treatment pressure, expression of preference and impact on co-existing conditions for the OHS population.

1.7.1.2. The quality of the evidence

OSAHS

There was evidence from 48 studies: 36 studies compared auto-CPAP with fixed level CPAP, 6 studies compared non-invasive ventilation (NIV) with fixed level CPAP, and 6 studies compared addition of humidification to fixed CPAP with fixed level CPAP. The populations recruited to the studies were predominantly male with a recent diagnosis of OSAHS. At baseline, the study populations had high BMI and AHI scores, and symptom scores indicated that they had excessive daytime sleepiness.

Data on tolerability outcomes (nasal blockage, dry mouth, tolerance of treatment pressure and mask leak) used different scales to capture these outcomes. Data were presented narratively for studies where data could not be analysed. Hence the comparative effects on tolerability outcomes are uncertain. The committee took this very low quality data into account while interpreting the evidence for decision making.

All evidence was in people with moderate to severe sleep apnoea (AHI >/= 15 but <30 moderate and AHI >/= 30 severe); however the majority of the studies were in people with severe sleep apnoea.

The committee considered the clinical importance of AHI on a case by case basis, taking into consideration the baseline AHI and the improvement in severity of sleep apnoea.

The quality of the evidence varied from high to very low quality. The majority of the evidence was downgraded due to due to risk of bias, inconsistency and imprecision. Risk of bias was most commonly due to selection bias and lack of blinding. Where there was heterogeneity in the evidence for an outcome, outcomes were downgraded for inconsistency as sub-group analysis was not conducted as data was from the Cochrane review. The committee also acknowledged that some uncertainty existed across the effect sizes seen within the evidence, with some confidence intervals crossing the MID thresholds or line of no effect. The committee took into account the quality of the evidence, including the uncertainty in their interpretation of the evidence.

OHS

There was evidence from 9 studies - 3 studies compared non-invasive ventilation (NIV) with lifestyle advice only, 3 studies compared non-invasive ventilation (NIV) with CPAP, 1 study compared non-invasive ventilation (NIV), CPAP and lifestyle advice and 2 studies compared volume assured non-invasive ventilation (NIV) with fixed non-invasive ventilation (NIV). All studies in the review included patients with severe sleep apnoea except for one study which had a mixed population including both moderate and severe sleep apnoea, and one that excluded patients with severe OSAHS. The quality of the evidence varied from high to very low quality; the majority of the evidence was downgraded due to risk of bias, inconsistency and imprecision. Risk of bias was most commonly due to selection bias and lack of blinding. Where there was heterogeneity in the evidence for an outcome, pre-specified subgroup analyses did not explain the variation in effect sizes. As a result, many outcomes were downgraded for inconsistency. The committee also acknowledged that some uncertainty existed across the effect sizes seen within the evidence, with some confidence intervals crossing the MID thresholds or line of no effect. The committee took this in to account in their interpretation of evidence.

COPD-OSAHS overlap syndrome

No evidence was identified for people with COPD-OSAHS overlap syndrome.

1.7.1.3. Benefits and harms

OSAHS

The evidence was available for people with moderate to severe OSAHS; however the majority of the studies in all three comparisons listed below were in people with severe OSAHS.

Auto CPAP vs fixed level CPAP

The evidence suggested that there was no clinically important difference between auto CPAP and fixed level CPAP for the outcomes of machine usage, number of participants who used CPAP therapy > 4 hours per night, symptoms (Epworth Sleepiness Scale), withdrawal, quality of life (measured by FOSQ, SAQLI and SF-36), Apnoea Hypopnoea Index (events/hr), arousals (events/hr), blood pressure, intolerable treatment pressure, mask leak and stuffy nose.

Overall there was no clinically important difference between auto CPAP and fixed level CPAP for the outcome treatment pressure, but there was a high degree of statistical variation. Despite the different mechanisms used to deliver mask pressure between the devices (auto CPAP and fixed level CPAP), in some studies the delivered treatment pressure was equivalent between auto-CPAP and fixed level CPAP, whilst in others the mean treatment pressure in auto-CPAP was between 3 and 5 cm H20 lower. Differences in algorithms used by the different machines used to alter pressure (e.g. forced oscillation), variation in peak treatment pressure within study populations and the selection of participants on the basis of high treatment pressure requirements, could contribute to the conflicting results. We consider the certainty of evidence for this outcome to be low because of this degree of variation. The committee acknowledged that in some OSAHS patients the lower mean pressure delivery from auto CPAP may be beneficial as it may lead to better tolerability, and in turn increase adherence to therapy.

There was also no clinically important difference between auto CPAP and fixed level CPAP for the outcome patient preference. However the results from the studies indicated wide variation between users of CPAP in terms of how they respond to the different modes of pressure delivery. In eight of the 14 studies reporting this outcome, there was a numerically superior preference for auto-CPAP over either fixed level CPAP, or neither treatment. However, in 6 studies the preference was in the opposite direction. There was no obvious explanation for this apparent discrepancy in terms of study design and technology of active interventions. Narrative evidence for the outcomes mask leak, tolerance for treatment pressure and nasal blockage was inconsistent and this was based on very low quality evidence.

Non-invasive ventilation (NIV) vs fixed level CPAP

The evidence suggested that there was no clinically important difference between non-invasive ventilation (NIV) and fixed level CPAP for any of the following outcomes: machine usage (hours/night), symptoms (Epworth Sleepiness Scale), withdrawal, quality of life (measured by SAQLI and SF-36), Apnoea Hypopnoea Index (events/hr), patient preference, dry mouth, mask intolerance and treatment comfort.

There was clinically important benefit of non-invasive ventilation (NIV) compared to fixed level CPAP for the outcome dry mouth. The committee however were not confident of this outcome as there was some uncertainty around the effect estimate and it was based on one small study.

Heated humidification with fixed pressure CPAP vs fixed level CPAP alone

The evidence suggested that there was no clinically important difference between heated humidification with fixed level CPAP and fixed level CPAP alone for machine usage, symptoms (Epworth Sleepiness Scale), withdrawal, quality of life (measured by SF-36), Apnoea Hypopnoea Index (events/hr) and patient preference. There was a clinically important benefit of heated humidification + fixed level CPAP for nasal symptoms such as runny nose and congested nose (from dichotomous outcomes); however continuous data for the same outcomes did not show any clinically important difference between the two groups.

CPAP treatment options for mild/moderate/severe OSAHS-committee’s consideration of the evidence to make recommendations

The NICE technology appraisal guidance TA139 on continuous positive airway pressure for the treatment of obstructive sleep apnoea/hypopnoea syndrome¹⁷⁵ recommends CPAP as a treatment option for moderate and severe OSAHS. In line with this, the committee agreed that CPAP should be first-line treatment for people with moderate and severe OSAHS. The evidence for use of CPAP in mild OSAHS is considered separately in Evidence Review E.

In the evidence reviewed for types of CPAP, most of the studies compared auto-CPAP with fixed level CPAP and measured machine usage, symptoms and AHI. There was weaker evidence (few studies) for quality of life. The evidence showed fixed level and auto CPAP to be equally effective and auto-CPAP to be more costly and therefore the committee recommended fixed level CPAP as first choice. However, some people, particularly those in whom high pressures are only needed part of the time, find auto-CPAP more comfortable and effective than fixed-level CPAP. For others, telemonitoring may not be possible because of technological constraints such as the lack of availability of internet or poor internet connection, auto-CPAP should be an option in these cases. The committee were also aware that some hospitals get significant discount on auto-CPAP devices which might make them more cost effective. Therefore, the committee agreed that if auto-CPAP is available at the same or lower cost than fixed-level CPAP, auto CPAP could be considered.

The committee based on their experience discussed the advantages of telemonitoring. These include early night-by-night access to data which can lead to early detection of problems such as mask leaks or persistent respiratory events of sleep apnoea, and the ability to monitor that OSAHS so that it continues to be effectively controlled and the individual is adherent to therapy. Telemonitoring makes managing a person’s OSAHS more efficient for clinicians as they have ready access to the data should they need it. For example, if contacted by a person with an issue they can use the data to help identify the problem (for example, mask leak or inadequate pressure) and take appropriate action without the need for a scheduled appointment. The committee agreed that video and telephone consultations along with telemonitoring is also advantageous to people with OSAHS as it can reduce the number of in-person visits needed to the sleep service. This can be particularly beneficial to patients who have difficulty in getting to clinics, for example, people who live in remote places or people with poor mobility, there would be fewer clinic visits in such cases. The reduction in the number of face-to-face consultations will also help reduce the risk of infection during the COVID-19 pandemic. Telemonitoring has facilitated remote assessment of patients during the coronavirus pandemic and has become a standard follow-up option in most sleep services. This use is likely to continue long term, because it is convenient for patients, enables them to assess progress themselves and allows access to efficacy and adherence data whenever needed, for example, for problem solving, routine follow-up and to complete DVLA reports.

The costs of telemonitoring were also discussed and the committee noted that in their experience, telemonitoring is included in the price of the machine for 12 months. Based on this they agreed that telemonitoring should be offered alongside CPAP for the first 12 months of treatment, and considered beyond 12 months where optimal control of symptoms and AHI has not been achieved, or to help with solving problems that people with OSAHS might experience. However, some people, particularly those in whom high pressures are only required for part of the time, find auto CPAP significantly more comfortable and effective than fixed level CPAP. For others, telemonitoring may not be possible because of technogical constraints such as the lack of availalblity of internet or poor internet connection. The committee agreed that auto-CPAP should be available in these cases. The committee discussed that initial pressure setting for CPAP is important to help ensure patient adherence to therapy and improve important outcomes, but they agreed that this should be a clinical decision individual to each person with OSAHS.

People who have previously used CPAP prior to study entry are under-represented in the studies included in the review. The results of the studies that recruited from this population do not provide evidence of substantially different results in terms of either usage or functional outcomes in these groups.

The evidence was available for people with moderate to severe OSAHS; the committee agreed that the data could be extrapolated to people with mild OSAHS as well.

The committee discussed that there was a variation in practice in the UK in the use of fixed level CPAP and auto CPAP, with bigger centres generally using fixed level CPAP and smaller centres using auto CPAP.

Given the low quality evidence and uncertainty about the cost-effectiveness between auto and fixed-level CPAP the committee made a research recommendation to help inform future guidelines (see Appendix J:). The committee did not make a research recommendation for long term use of telemonitoring as they believe telemonitoring is already becoming common practice and will remain so in the future. They agreed it is more convenient for CPAP users and clinicians. It also saves time as users do not need to download data and post or take it in to the sleep service.

Evidence suggested that there was clinically important benefit of addition of heated humidification for nasal symptoms such as runny nose and congested nose, but the results were not consistent. The committee from their experience of current practice agreed that addition of humidification to CPAP should be considered for people with all severities of OSAHS who have nasal symptoms, as it could reduce side effects causing upper airway symptoms and subsequently improve adherence and treatment effectiveness.

The evidence for CPAP compared to conservative management and other interventions in mild OSAHS population is in Evidence report E and the evidence for telemonitoring is in Evidence report L.

The committee agreed that all people with OSAHS should also be offered lifestyle advice including weight loss, smoking cessation, sleep hygiene and reduced alcohol intake alongside the chosen treatment method as obesity increases the prevalence and severity of OSAHS, smoking causes upper airway inflammation which can exacerbate symptoms, and excess alcohol before sleep reduces upper airway tone increasing apnoeas, and reduces sleep quality. Sleep hygiene recommendations include ensuring adequate sleep time, avoiding caffeine and stimulants that interfere with sleep prior to bedtime, exercising regularly, having a quiet, comfortable, darkened bedroom, and winding down before sleep For lifestyle advice refer to NICE guidelines on stop smoking interventions and services, preventing excess weight gain, obesity and alcohol-use disorders: prevention.¹⁷⁰^, ¹⁷²^–¹⁷⁴

The recommendations for CPAP reflect current practice in most centres. Some sleep services currently using auto CPAP, may switch to fixed level CPAP for new patients starting CPAP, which is likely to be cost saving.

OHS

Where the severity of OSAHS associated with OHS was characterised, evidence was for severe rather than mild and moderate OSAHS. The committee noted that differentiation into OHS with OSAHS or OHS without OSAHS (usually with nocturnal hypoventilation) based on the diagnostic sleep study is helpful.

Non-invasive ventilation (NIV) vs lifestyle change

In people with OHS (both with and without severe OSAHS), the evidence suggested that there was clinically important benefit of non-invasive ventilation for change in PaCO2, PaO2, change in AHI change in ODI, and symptoms (change in ESS), compared to lifestyle changes, although there was some uncertainty around the effect estimates. The evidence suggested that there were no clinically important differences between non-invasive ventilation and lifestyle for change in HbA1c and change in systolic blood pressure. There was inconsistency in quality of life outcomes with benefit of non-invasive ventilation for quality of life measured by FOSQ and no difference between non-invasive ventilation and lifestyle when measured by SF-36. All outcomes were measured at 2 months follow-up.

In people with OHS without severe OSAHS at 3 years follow-up, the evidence suggested that there was clinically important benefit of non-invasive ventilation for PaCO2 and ESS compared to lifestyle changes, although there was some uncertainty around the effect estimates. The evidence suggested that there were no clinically important differences between non-invasive ventilation and lifestyle for systolic blood pressure, diastolic blood pressure, mortality and cardiovascular events, however there was some uncertainty around the effect estimates. There was inconsistency in quality of life outcomes with benefit of non-invasive ventilation for quality of life measured by FOSQ and SF-36 physical at 3 years and no difference between non-invasive ventilation and lifestyle for SF-36 mental. All outcomes were measured at 3 years follow-up.

It is important to note these studies included stable patients (who do not have acute ventilatory failure) who tolerated and showed an adequate response to CPAP. All studies excluded people with acute ventilatory failure, or who did not tolerate and respond to CPAP in a preliminary trial, and therefore recommendations for management in these people is based on expert opinion, with provision of NIV.

Non-invasive ventilation (NIV) vs CPAP

In clinically stable patients with OHS (who do not have acute ventilatory failure) and severe OSAHS the evidence suggested that there was no clinically important difference between non-invasive ventilation and CPAP for quality of life (measured by SF-36), adherence, change in AHI, and change in ODI, change in PaCO2, change in symptoms, systolic blood pressure, cardiovascular events and hospitalisation per patient per year. There was clinically important benefit of non-invasive ventilation for mortality and the outcome FOSQ. The apparent mortality benefit was based on a small number of events and the committee viewed this result with caution.

There were no studies of CPAP in patients with OHS in whom severe OSAHS had been excluded since conceptually CPAP is not a treatment for hypoventilation that is not a result of obstructive events. Therefore in this group, non-invasive ventilation is recommended. However the committee agreed that research of the efficacy of CPAP in this patient group would be of interest, since mechanisms of CPAP benefit may extend beyond simply splinting the upper airway. As the committee made a strong recommendation for this population, they did not make a research recommendation.

There were no studies of CPAP vs non-invasive ventilation in people with acute ventilatory failure; the committee recommended non-invasive ventilation in this patient group since rapid improvement in hypercapnia is a priority, and patients are often too unwell to discontinue treatment whilst sleep studies are carried out. The committee agreed there are no real harms if non-invasive ventilation is indicated and it is tolerated better than CPAP.

Fixed NIV vs volume assured NIV

The evidence suggested that there was no clinically important difference between fixed NIV and volume assured non-invasive ventilation for disease specific quality of life, symptoms (Epworth Sleepiness Scale), PaCO2, PaO2, Adherence (hours per night), AHI and ODI.

CPAP vs lifestyle (dietary and lifestyle counselling)

The evidence suggested that there was clinically important benefit of CPAP for change in symptoms (ESS), change in AHI, change in ODI compared to lifestyle (dietary and lifestyle counselling. However there was some uncertainty around the effect estimate for the outcome ESS. The evidence suggested that there was no clinically important difference between CPAP and lifestyle for change in PaCO2. There was inconsistency in quality of life outcomes with benefit of CPAP for quality of life SF-36 mental and FOSQ and no difference between NIV and lifestyle for SF-36 physical. There was no evidence for CPAP vs non-invasive ventilation for management of patients with obesity hypoventilation without severe OSAHS.

Treatment options for OHS-committee’s consideration of the evidence to make recommendations

The committee’s experience is that approximately 90% of the people with OHS have associated OSAHS of at least mild severity, and 70% severe OSAHS. The evidence was limited to people with OHS and severe OSAHS who were stable (who do not have acute ventilatory failure). It showed that both CPAP and non-invasive ventilation are beneficial compared with lifestyle changes, and that there was little difference in effectiveness between these treatments. There was no evidence comparing CPAP and non-invasive ventilation for people with acute ventilatory failure.

OSAHS and obesity are associated with increased cardiovascular disease, type 2 diabetes and mortality, and the committee therefore agreed that advice regarding weight loss should be offered to all people with OHS to reduce their risk. The committee agreed that all people with OHS should also be offered lifestyle advice including weight loss, smoking cessation, sleep hygiene and reduced alcohol intake alongside the chosen treatment method as obesity increases the prevalence and severity of OHS, smoking causes upper airway inflammation which can exacerbate symptoms, and excess alcohol before sleep reduces upper airway tone increasing apnoeas, and reduces sleep quality. Sleep hygiene recommendations include ensuring adequate sleep time, avoiding caffeine and stimulants that interfere with sleep prior to bedtime, exercising regularly, having a quiet, comfortable, darkened bedroom, and winding down before sleep. For lifestyle advice refer to NICE guidelines on stop smoking interventions and services,¹⁷³ preventing excess weight gain,¹⁷² obesity¹⁷⁰ and alcohol-use disorders: prevention.¹⁷⁴

People with OHS who do not have acute ventilatory failure

In people with stable OHS and severe OSAHS, based on the evidence and their experience, the committee agreed that CPAP should be offered as a first line treatment because it is more cost-effective, simpler to set up and may be better tolerated than non-invasive ventilation, and it is effective even in mild to moderate hypercapnia. The committee discussed that it seems probable that hypercapnic ventilatory failure in the obese with severe obstructive sleep apnoea is driven in part by the increased work of breathing due to upper airway obstruction of severe OSAHS, rather than the obesity itself. Therefore the committee agreed that stable patients (who do not have acute ventilatory failure) with severe OSAHS could be effectively treated with CPAP alone to alleviate upper airway obstruction and associated severe OSAHS.

If symptoms do not improve, hypercapnia persists, AHI or ODI are not sufficiently reduced or CPAP is poorly tolerated, the committee agreed that treatment should be changed to non-invasive ventilation to control nocturnal hypoventilation.

In line with current practice the committee agreed that non-invasive ventilation should be considered for people with OHS and nocturnal hypoventilation who do not have OSAHS, or in whom OSAHS is not severe.

People with OHS and acute ventilatory failure

All studies excluded people with acute ventilatory failure, and therefore the recommendations for their management is based on committee experience. Although there was no direct evidence available, the committee were clear that non-invasive ventilation should be the first-line treatment for people with OHS and acute ventilatory failure because rapid improvement in hypercapnia is a priority. People in whom hypercapnia resolves may have a trial without non-invasive ventilation. In this instance, they should remain under review in case hypercapnia recurs and re-started on non-invasive ventilation, if necessary. Assessement with respiratory polygrahy on recovery should be carried out to to determine the need to treat long-term with CPAP or non-invasive ventilation. The committee agreed that people with residual OSAHS but minimal hypoventilation when stable can be switched to CPAP.

For people with OHS, the committee made separate recommendations for people who were stable (who do not have acute ventilatory failure)) and OHS patients with acute ventilatory failure.

The committee noted from their experience that long-term non-invasive ventilation therapy should be considered if hypercapnia persists. People in whom hypercapnia resolves may have a trial without non-invasive ventilation. In this instance, they should remain under review in case hypercapnia recurs, and should be assessed with respiratory polygraphy on recovery to determine the need to treat long-term with CPAP or non-invasive ventilation. The committee agreed that people with residual OSAHS but minimal hypoventilation when stable can be switched to CPAP.

Due to lack of evidence comparing auto vs fixed level CPAP in OHS, the committee did not specify the type of CPAP. The committee discussed whether evidence from people with OSAHS could be used for people with OHS. They agreed that the differences between these two groups are too great to allow them to make a consensus recommendation based on the evidence in OSAHS. They discussed whether there should be a research recommendation for auto vs fixed CPAP in OHS but decided against this because auto CPAP is likely to be less effective in this patient group than fixed CPAP as less time is spent at therapeutic pressure.

The committee stated that in current practice a trial of discontinuing non-invasive ventilation, carrying out respiratory polygraphy and considering conservative management or step-down to CPAP are not always undertaken, hence these steps would be a change in practice that is likely to result in less non-invasive ventilation use.

Based on the evidence reviewed for OSAHS and their experience of current practice, the committee agreed that addition of humidification to CPAP should be considered in people with OHS who have nasal symptoms, as it could reduce upper airway side effects and consequently improve adherence and treatment effectiveness.

COPD-OSAHS overlap syndrome

There was no evidence available for this population. The committee used their collective experience to make the recommendations. The committee agreed that treatment for this population depends on the level of hypercapnia when awake and asleep. People with more severe daytime hypercapnia (PaCO₂ greater than 7 kPa) caused by nocturnal hypoventilation, are likely to need non-invasive ventilation. This is based on extrapolation from data, not reviewed for this guideline but, in whom definite benefit of non-invasive ventilation has not been demonstrated when hypercapnia is modest (PaCO2 between 6 and 7 kPa and not associated with exacerbation of COPD). The decision to treat with CPAP in the absence of a PaCO2 >7kPa is based upon clinical severity and symptom burden of OSAHS. The committee therefore recommended that CPAP should be considered in people with COPD-OSAHS overlap syndrome if they have confirmed OSAHS from a sleep study and if their PaCO2 is less than or equal to 7.0 kPa, and non-invasive ventilation should be considered if the PaCO2 is higher. Based on the evidence reviewed for OSAHS and their experience of current practice, the committee agreed that addition of humidification to CPAP should be considered for people with all COPD-OSAHS overlap syndrome who have nasal symptoms, because it may reduce upper airway side effects and consequently improve adherence and treatment effectiveness.

The committee agreed that all people with COPD-OSAHS overlap syndrome should also be offered lifestyle advice including weight loss, smoking cessation, sleep hygiene and reduced alcohol intake alongside the chosen treatment method as obesity increases the prevalence and severity of COPD-OSAHS overlap syndrome, smoking causes upper airway inflammation which can exacerbate symptoms, and excess alcohol before sleep reduces upper airway tone increasing apnoeas, and reduces sleep quality. Sleep hygiene recommendations include ensuring adequate sleep time, avoiding caffeine and stimulants that interfere with sleep prior to bedtime, exercising regularly, having a quiet, comfortable, darkened bedroom, and winding down before sleep. For lifestyle advice refer to NICE guidelines on stop smoking interventions and services,¹⁷³ preventing excess weight gain,¹⁷² obesity¹⁷⁰ and alcohol-use disorders: prevention.¹⁷⁴

The committee agreed that the recommendations reflect current actual practice.

As there was no evidence for CPAP compared to non-invasive ventilation for people with COPD-OSAHS overlap syndrome, the committee made a research recommendation to inform future guidance as to in which scenario CPAP or non-invasive ventilation is preferred for people with COPD-OSAHS overlap syndrome.

Reducing the risk of transmission of infection when using CPAP or non-invasive ventilation

The committee agreed that CPAP and non-invasive ventilation are aerosol generating procedures and where there is a risk of airborne infection, such as during a time of COVID-19 risk, appropriate infection control precautions should be taken, which may include device modification.

1.7.2. Cost effectiveness and resource use

OSAHS

NICE’s technology appraisal TA139¹⁷⁵ recommended positive airway pressure devices as a treatment option for adults with moderate or severe symptomatic OSAHS. However, TA139 does not specify the type of positive airway pressure devices that should be used. In the NHS supply catalogue, the acquisition cost of auto-CPAP was over £100 higher than fixed level CPAP, depending on the type and brand of device, although the committee are aware that some hospitals get significant discounts. Positive airway pressure devices are a lifetime intervention and a replacement device is required every 5-7 years or 10,000 hours). It has been estimated that the treated OSAHS population in the UK is 330,000²²⁰ or even as high as 700,000⁹² and the currently untreated population is considerably larger therefore there is potential for a significant resource impact.

As there was no important differences in the key clinical outcome measures, the committee agreed that costs were important when considering fixed-level CPAP versus auto-CPAP. Therefore, a cost-comparison analysis was incorporated into the economic model developed for the guideline to identify the least expensive device over a lifetime horizon. The committee identified five key strategies which sufficiently captured the different methods of using fixed-level CPAP or auto-CPAP. The lowest cost strategies were fixed-level CPAP with autotitration and fixed-level CPAP with telemonitoring for the first year. The committee decided to recommend telemonitoring as a tool for improving adherence but also to reduce contact with patients that might lead to transmission of infectious disease (see Evidence reports L and M).

After the development of this model, a published cost-consequences analysis was found that was based on a trial with one-year follow-up in Switzerland. This too found a trend towards lower OSAHS treatment costs for fixed-level CPAP, although the trend for all health care costs favoured auto-CPAP. Neither difference was statistically significant.

The committee concluded that fixed-level CPAP is generally likely to be less costly and more efficient than auto-CPAP but there is some uncertainty and this could be affected by local factors including the prices of devices and consumables or a need to reduce staff time spent on pressure adjustment.

The committee recommended that fixed-level be offered first-line. They recommended that auto-CPAP should be considered in situations when there is a need for high pressure only for certain times during sleep or if a patient is not tolerant to fixed-level CPAP. There might be local circumstances where auto-CPAP can be purchased and administered at the same or lower cost as fixed-level CPAP. In this circumstance, the committee decided that auto-CPAP could be considered, if this price is guaranteed for an extended period of time.

In the economic analyses of treatment for mild OSAHS and diagnostic strategies, CPAP was cost effective compared to both conservative management and mandibular advancement splints, regardless of whether the cost of fixed-level CPAP or auto-CPAP were used in the model (see Evidence reports D and E).

There was no cost effectiveness evidence for the use of humidification and the clinical evidence was mainly related to increased machine usage. The committee formed a consensus recommendation that humidification need not be offered first line but that it should be added to CPAP for people with OSAHS who have nasal or oral symptoms, to improve the quality of their sleep and optimise adherence to treatment. This addition is current practice (the committee estimated that it would apply to 30% to 50% of people receiving CPAP devices for OSAHS).

OHS

A single published economic evaluation was found comparing CPAP with non-invasive ventilation (NIV) for people with OHS. This study in a Spanish setting did not evaluate patient outcomes but found that CPAP was cost saving compared to NIV

The clinical evidence showed significant benefits for CPAP over lifestyle intervention for a number of outcomes including quality of life, which the committee considered were likely to be cost effective. The clinical evidence did not show important benefits for NIV over CPAP. The committee divided the obesity hypoventilation population into two categories: 1) a stable population 2) a population with acute ventilatory failure.

In the population who are stable and have severe OSAHS, the committee recommended the provision of CPAP as a first line treatment and only a switch to NIV if hypercapnia persists after follow up. The committee suggested that this would be a significant change in practice as historically, NIV would usually have been offered as first line. The committee explained this would achieve substantial cost savings. If there is no OSAHS in the stable OHS population, the committee formed a consensus recommendation based on their experience, that people in this group should be considered for NIV. As this is already occurring in current practice, the recommendation is expected to be cost-neutral. The committee also considered whether CPAP devices would be appropriate for this stable OHS group (without OSAHS) over the more expensive NIV, however, the committee concluded that in the absence of OSA, alveolar ventilation must be augmented using pressure support ventilation and therefore it would be physiologically inappropriate to use CPAP in this situation.

For people with acute ventilatory failure, as the absence of NIV would have the potential to result in death, the committee were of the strong view that all people in this category should be offered NIV. As this is already routinely offered in current practice, this recommendation would be cost-neutral. In those instances where hypercapnia is resolved, the committee recommended that the need for ongoing NIV, as opposed to CPAP, be reviewed. However follow-up including respiratory polygraphy to ensure that sleep disordered breathing is well controlled, and hypercapnia has not recurred, wasconsidered advisable.

The recommendations on the choice of pressure variant device for the OHS population as a whole is likely to result in cost-savings for the NHS from reduced use of NIV but this will be partly offset by the need for additional sleep studies and CO₂ testing.

COPD-OSAHS overlap syndrome

There was no relevant published clinical or economic evidence found for this population.

The committee made consensus recommendations that are in line with current practice and therefore there is not expected to be significant resource impact:

The less costly treatment CPAP as the first-line treatment
Consideration of non-invasive ventilation for people with hypercapnia
Consideration of supplemental oxygen therapy in people whose symptoms persist.

1.7.3. Other factors the committee took into account

The views of lay members were taken into consideration when reviewing types of devices such as fixed level CPAP, auto CPAP, non-invasive ventilation and whether humidification is used or not. The lay member’s emphasised above all that it is important to provide a personalised therapy. This is as much a consideration of which device should be used in conjunction with the best evidence available but also and more importantly when considering mask interfaces.

There are a number of different services throughout the country providing fixed level CPAP, auto CPAP and non-invasive ventilation. Some of the services have historically chosen particular device options due to other resource limitations. For example using an auto CPAP may mean that less clinic appointments are needed for device titration. The advent of more effective telemonitoring ability and reduction in cost means that remote monitoring is available across all devices. Therefore the ability to clinically manage and change patient therapy can be provided without a face to face clinic appointment but though telephone, telemonitoring or other electronic communication strategy. This ability to use telemonitor as well as use virtual clinics can change the way that services provide ongoing follow up support for patients. This will be particularly helpful in rural and logistically challenging regions of the country (see evidence report for detailed discussion of telemonitoring in chapter L).

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Appendices

Appendix A. Review protocols

Table 16. Review protocol: Positive Airway Pressure therapy variants for OSAHS/OHS/ COPD-OSAHS overlap syndrome (PDF, 370K)

Table 17. Health economic review protocol-OSAHS (PDF, 226K)

OHS (PDF, 215K)

Appendix B. Literature search strategies

Sleep Apnoea search strategy 8_positive airway pressure devices

This literature search strategy was used for the following reviews;

What is the comparative clinical and cost effectiveness of different types of positive airway pressure devices (for example, fixed-pressure CPAP, variable-pressure CPAP, bi-level positive airway pressure or other modes of non-invasive ventilation) for managing obstructive sleep apnoea/hypopnoea syndrome, obesity hypoventilation syndrome and COPD-OSAHS overlap syndrome?

The literature searches for this review are detailed below and complied with the methodology outlined in Developing NICE guidelines: the manual.¹⁷¹

For more information, please see the Methods Report published as part of the accompanying documents for this guideline.

B.1. Clinical search literature search strategy (PDF, 315K)

B.2. Health Economics literature search strategy (PDF, 385K)

Appendix C. Clinical evidence selection

Figure 1. Flow chart of clinical study selection for the review of PA variants for OSAHS and OHS (PDF, 180K)

Appendix D. Clinical evidence tables

OSAHS (PDF, 267K)

OHS (PDF, 340K)

Appendix E. Forest plots

OSAHS (PDF, 309K)

OHS (PDF, 419K)

Appendix F. GRADE tables

OSAHS (PDF, 382K)

OHS (PDF, 394K)

Final

Intervention evidence review

Developed by the National Guideline Centre, hosted by the Royal College of Physicians

Disclaimer: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and, where appropriate, their carer or guardian.

Local commissioners and providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.

NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn.

Bookshelf ID: NBK574326PMID: 34613675

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National Guideline Centre (UK). Positive airway pressure therapy variants for OSAHS, OHS and COPD–OSAHS overlap syndrome: Obstructive sleep apnoea/hypopnoea syndrome and obesity hypoventilation syndrome in over 16s: Evidence review F. London: National Institute for Health and Care Excellence (NICE); 2021 Aug. (NICE Guideline, No. 202.)
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Positive airway pressure therapy variants for OSAHS, OHS and COPD–OSAHS overlap syndrome

1. Positive airway pressure therapy variants

1.2. Introduction

1.3. PICO table

1.4. Clinical evidence

1.4.1. Included studies

OSAHS population

OHS population

COPD-OSAHS overlap syndrome

1.4.2. Excluded studies

1.4.3. Summary of clinical studies included in the evidence review -OSAHS

1.4.4. Summary of clinical studies included in the evidence review –OHS population

1.4.5. Quality assessment of clinical studies included in the evidence review –OSAHS population

1.4.6. Quality assessment of clinical studies included in the evidence review – OHS population

Narrative results

Auto CPAP vs fixed CPAP

Nasal blockage (very low quality)

Tolerance of treatment pressure (very low quality)

Mask leak (very low quality)

NIV vs fixed CPAP

Tolerability outcomes (very low quality)

1.5. Economic evidence

1.5.1. Included studies

1.5.2. Excluded studies

1.5.3. Summary of studies included in the economic evidence review

1.5.4. Unit costs

1.5.5. Health economic modelling

1.5.5.1. Strategies compared

1.5.5.2. Methods and data sources (Summary)

Results

1.6. Economic evidence statements

1.7. The committee’s discussion of the evidence

1.7.1. Interpreting the evidence

1.7.1.1. The outcomes that matter most

1.7.1.2. The quality of the evidence

OSAHS

OHS

COPD-OSAHS overlap syndrome

1.7.1.3. Benefits and harms

OSAHS

Auto CPAP vs fixed level CPAP

Non-invasive ventilation (NIV) vs fixed level CPAP

Heated humidification with fixed pressure CPAP vs fixed level CPAP alone

CPAP treatment options for mild/moderate/severe OSAHS-committee’s consideration of the evidence to make recommendations

OHS

Non-invasive ventilation (NIV) vs lifestyle change

Non-invasive ventilation (NIV) vs CPAP

Fixed NIV vs volume assured NIV

CPAP vs lifestyle (dietary and lifestyle counselling)

Treatment options for OHS-committee’s consideration of the evidence to make recommendations

People with OHS who do not have acute ventilatory failure

People with OHS and acute ventilatory failure

COPD-OSAHS overlap syndrome

Reducing the risk of transmission of infection when using CPAP or non-invasive ventilation

1.7.2. Cost effectiveness and resource use

OSAHS

OHS

COPD-OSAHS overlap syndrome

1.7.3. Other factors the committee took into account

References

Appendices

Appendix A. Review protocols

Appendix B. Literature search strategies

Appendix C. Clinical evidence selection

Appendix D. Clinical evidence tables

Appendix E. Forest plots

Appendix F. GRADE tables

Appendix G. Health economic evidence selection

Appendix H. Health economic evidence tables

Appendix I. Excluded studies

Appendix J. Research recommendations

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