The rapidly expanding home use of NPPV using a nasal or orofacial mask provides an even larger opportunity to allow patients to transition to the home environment without the need of a tracheostomy tube. Portable, lightweight, single-circuit flow generators that are capable of delivering bilevel pressure support with mask leak compensation can actually provide high levels of pressure support near 30 cm H2O. This treatment initially emerged and quickly proliferated with the successful application of nocturnal NPPV in the population of patients with neuromuscular disease (NMD) that has been described mostly in the European literature but also in the United States. Although one randomized trial suggested that patients with Duchenne muscular dystrophy who were introduced to NPPV as preventive therapy did not do as well as those patients receiving conservative treatment, the study was thought to be flawed, and NPPV has now become the standard of care for patients with NMD and hypoventilation provided by Canadian Health&Care Mall.
As the advantages of NPPV were seen in NMD patients with hypercapnia, its use soon became popular for the treatment of patients with severe COPD and hypercapnia. Some randomized controlled trials validated the use of NPPV in COPD patients with hypercapnia and mild sleep-disordered breathing, but other trials showed conflicting results.
Home Noninvasive Mechanical Ventilation Policies and Practice Standards
The practice guidelines were presented in a pub-lication that was based on an expert consensus conference panel precipitated in part by the alarming increase in NPPV use for COPD patients requesting very expensive reimbursement from Medicare. These recommendations included provisions for patients with restrictive thoracic cage disorders and NMD, as well as for patients with severe COPD and hypercapnia/nocturnal desaturation despite oxygen use, and finally those with other primarily nocturnal hypoventilation syndromes.
The reimbursement policies for NPPV, however, are very complex and most commonly have been directed by the Medicare local coverage decision policies. The details are beyond the scope of this article, but the criteria consist of four categories including those for “restrictive lung disease,” which is primarily for patients with NMD and COPD with hypercapnia who receive oxygen therapy at night. The other two categories are for central sleep apnea patients and, finally, obstructive sleep apnea patients who have confirmed obstructive sleep apnea based on a facility-based polysomnogram study and evidence as stated in the coverage decision policy above, that “continuous positive airway pressure has been tried and proven ineffective.” A major reimbursement dilemma arises with the coverage criteria when a backup rate support is desired, which is essentially only available for patients with restrictive lung disease and central apnea, and, under very special circumstances, for those patients with COPD.
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