To our knowledge, this is the first randomized controlled trial that compares PAP therapies in patients with chronic hypercapnic respiratory failure in the setting of concurrent obesity and COPD. Compared to baseline, 3 months of PAP therapy resulted in significant decreases in PaCO 2 in both BPAP and CPAP arms, with BPAP S mode superior to CPAP in reducing PaCO 2 in our study population. BPAP allocation was also associated with a greater improvement in FEV 1 , forced vital capacity, and the mental component of SF-36 when compared to CPAP. There were no significant differences between the two arms in other secondary outcomes and PAP adherence.
In clinical trials involving OHS patients with severe OSA and without airways disease (forced expiratory ratio > 0.7), BPAP and CPAP had similar efficacy in improving ventilatory failure. As sleep apnea plays an important role in the development of hypercapnia in this OHS phenotype, CPAP is effective in resolving upper airway obstruction. CPAP also has a volume- inflation effect, which improves V/Q mismatch due to small airway closure and over time improves central ventilatory drive.
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