The HOT-HMV randomised trial evaluated whether home non-invasive ventilation added to home oxygen could improve outcomes after a life-threatening COPD exacerbation in patients with persistent hypercapnia. The study enrolled patients who remained hypercapnic after recovery from an acute episode and compared home oxygen alone with oxygen plus home NIV. Adding home NIV substantially prolonged the time to hospital readmission or death over the one-year follow-up period. The benefit supports a targeted approach to long-term ventilatory support: not every patient with COPD requires home NIV, but carefully selected patients with persistent hypercapnia after an acute decompensation may benefit. The trial is especially relevant because it links inpatient critical-care decisions with longer-term respiratory management. Persistent hypercapnia identifies a population with ongoing ventilatory insufficiency that may not be addressed by oxygen therapy alone. For clinicians, the practical message is to reassess gas exchange after recovery rather than assuming that correction of the acute exacerbation represents complete physiologic recovery. Home NIV requires appropriate patient selection, interface support, adherence monitoring and adequate ventilator settings. The study therefore supports an integrated pathway that begins with acute NIV in the hospital and, for selected patients, transitions to chronic ventilatory support aimed at reducing recurrent admissions and improving stability.