This document discusses the use of non-invasive ventilation (NIV) such as CPAP and BiPAP in the treatment of acute and chronic heart failure. For acute heart failure with pulmonary edema:
1) Meta-analyses found that NIV decreases the need for intubation and reduces hospital mortality compared to standard oxygen therapy alone.
2) NIV is not associated with increased risk of myocardial infarction.
3) CPAP and BiPAP provide similar benefits but CPAP has some advantages of being simpler technology.
4) NIV can be used in the pre-hospital setting for cardiogenic pulmonary edema.
For chronic heart failure, NIV improved left ventricular ejection fraction and BNP
3. Heart-Lung interactions
• The respiratory muscles
have to generate large
negative swings in pleural
pressure to start inspiratory
flow and maintain adequate
tidal volumes
• This increase in negative
intrathoracic pressure
aggravates pulmonary
edema by increasing both
preload and afterload
10. Effects of CPAP in CHF
AM J RESPIR CRIT CARE MED 1997;155:500-505
PAWP In 9 patients with acute left heart failure
(PAOP ~ 18 mm Hg, and CI ~ 2.8 l/min/m2)
11. Effects of CPAP in CHF
AM J RESPIR CRIT CARE MED 1997;155:500-505
Pressure-
Time index
Respiratory
muscles
C
R
12. Effects of CPAP in CHF
- Decrease negative swings in intrathoracic pressure -
AM J RESPIR CRIT CARE MED 1997;155:500-505
13. AM J RESPIR CRIT CARE MED 1997;155:500-505
Effects of CPAP in CHF
- Decrease work of breathing -
14. Hemodynamic effects of CPAP in CHF
Stroke volume index
AM J RESPIR CRIT CARE MED 1997;155:500-505
• No significant change in SVI
• Mean transmural filling pressures decreased significantly with CPAP, suggesting a
better cardiac performance
15. Potential Mechanisms of CPAP and NIV in
Patients With Acute Cardiogenic Pulmonary Edema
• CPAP
• Reduced work of breathing
• Increased cardiac output from reduced pre-load and
after-load
• Reduced mitral regurgitation
• Increased functional residual capacity
• Reduced atelectasis
• Reduced right-to-left intrapulmonary shunt
• NIV
• Same benefits as CPAP
• Unloads the respiratory muscles
Respir Care 2009;54(2):186 –195
16. Three Interventions in Cardiogenic Pulmonary
edema (3CPO) trial
• 26 emergency rooms, United Kingdom
• 1069 patients
• Standard oxygen therapy, 367 patients
• CPAP (5 to 15), 346 patients
• NIPPV (IPAP, 8 to 20; PEEP, 4 to 10), 356 patients
N Engl J Med 2008;359:142-51
24. Higher AMI in BiPAP than CPAP
Crit Care Med 1997; 25:620-628
25. Meta-analysis
NIV is not associated with increased myocardial infarction
Eur Respir J 2017; 50: 1602426
26. Predicting the success of noninvasive positive pressure ventilation
in emergency room for patients with acute heart failure
• 343 patients
Journal of Cardiology (2011) 57, 107—114
27. BiPAP-Synchrony BiPAP-Vision
Predicting the success of noninvasive positive pressure ventilation
in emergency room for patients with acute heart failure
Cut-off: pH value of 7.20 Cut-off: pH value of 7.03
Journal of Cardiology (2011) 57, 107—114
28. Should a trial of CPAP prior to hospitalization be
used to prevent deterioration in patients with ARF
due to cardiogenic pulmonary edema ?
29. A trial of CPAP prior to hospitalization
Eur Respir J 2017; 50: 1602426
30. BIPAP vs CPAP
• CPAP has some advantages over bilevel NIV
• Simpler technology
• Easier synchronization
• Less expensive equipment
• The current evidence summary demonstrates
significant benefit of both interventions compared
with standard care, and insufficient evidence to
recommend one modality over the other
Eur Respir J 2017; 50: 1602426
31. Most trials of both CPAP and NIV generally
excluded patients with acute myocardial infarction
that required revascularization with thrombolytics
or invasive procedures !
37. NIV strategy according to different heart failure
conditions
World J Cardiol 2014 November 26; 6(11): 1175-1191
38. Take home messages
• In patient with acute CHF with pulmonary edema
(1) NIV decreases the need for intubation
(2) NIV reduced hospital mortality
(3) NIV is not associated with increased myocardial infarction
(4) CPAP and NIV have similar effects, but CPAP has some advantages
• NIV can be used for patients with cardiogenic pulmonary
edema in the pre-hospital setting
• NIV improved LVEF and BNP but did not improve overall
mortality in patients with chronic heart failure
Patients in cardiogenic shock were excluded in trials
Many trials excluded patients requiring acute revascularization
Some have excluded patients with acute coronary syndrome
40. NIV in Chronic heart failure
• In the present meta-analysis, use of NPPV plus
SMT improved LVEF and reduced plasma BNP level
but did not improve overall mortality in patients
with chronic heart failure.
41. Indication of positive airway pressure for each condition
World J Cardiol 2014 November 26; 6(11): 1175-1191
