Chest
Volume 160, Issue 5, November 2021, Pages e399-e408
Journal home page for Chest

Education and Clinical Practice: Special Features
Optimal NIV Medicare Access Promotion: Patients With Thoracic Restrictive Disorders: A Technical Expert Panel Report From the American College of Chest Physicians, the American Association for Respiratory Care, the American Academy of Sleep Medicine, and the American Thoracic Society

https://doi.org/10.1016/j.chest.2021.05.075Get rights and content

The existing coverage criteria for noninvasive ventilation (NIV) do not recognize the benefits of early initiation of NIV for those with thoracic restrictive disorders and do not address the unique needs for daytime support as the patients progress to ventilator dependence. This document summarizes the work of the thoracic restrictive disorder Technical Expert Panel working group. The most pressing current coverage barriers identified were: (1) delays in implementing NIV treatment; (2) lack of coverage for many nonprogressive neuromuscular diseases; and (3) lack of clear policy indications for home mechanical ventilation (HMV) support in thoracic restrictive disorders. To best address these issues, we make the following key recommendations: (1) given the need to encourage early initiation of NIV with bilevel positive airway pressure devices, we recommend that symptoms be considered as a reason to initiate therapy even at mildly reduced FVCs; (2) broaden CO2 measurements to include surrogates such as transcutaneous, end-tidal, or venous blood gas; (3) expand the diagnostic category to include phrenic nerve injuries and disorders of central drive; (4) allow a bilevel positive airway pressure device to be advanced to an HMV when the vital capacity is < 30% or to address severe daytime respiratory symptoms; and (5) provide additional HMV when the patient is ventilator dependent with use > 18 h per day. Adoption of these proposed recommendations would result in the right device, at the right time, for the right type of patients with thoracic restrictive disorders.

Key Words

neuromuscular
noninvasive
ventilations

Abbreviations

ALS
amyotrophic lateral sclerosis
BPAP
bilevel positive airway pressure
CMS
Centers for Medicare & Medicaid Services
EtPco2
end-tidal CO2
FSS
frequent and substantial servicing
HMV
home mechanical ventilation
MIP
maximal inspiratory pressure
NCD
national coverage determination
NIV
noninvasive ventilation
NMD
neuromuscular disease
ONMAP
Optimal NIV Medicare Access Promotion
TcCO2
transcutaneous CO2
TRD
thoracic restrictive disorder
VC
vital capacity

Cited by (0)

A complete list of the ONMAP Technical Expert Panel is presented in the Acknowledgments.

View Abstract