Non-Invasive Positive Pressure Ventilation in Heart Failure Patients: For Who, Wy & When?

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1 REUNIÃO CONJUNTA DOS GRUPOS DE ESTUDO DE CUIDADOS INTENSIVOS CARDÍACOS E DE FISIOPATOLOGIA DO ESFORÇO E REABILITAÇÃO CARDÍACA O L H Ã O 2 7 e 2 8 d e J a n e i r o Non-Invasive Positive Pressure Ventilation in Heart Failure Patients: For Who, Wy & When? Quais os doentes com insuficiência cardíaca que beneficiam de ventilação não-invasiva? L u i s R a p o s o U N I C A R V H o s p i t a l d e S a n t a C r u z C H L O

2 NIV has been has an important clinical role in both acute Increasing decompensate prevalence of chronic congestive kidney dysfunction HF & in chronic stable patients with BDS Non-Invasive Positive Pressure Ventilation Definition Basic principles & practical setup and hints Acute/decompensated heart failure (mostly ALE) Basic pathophysiology of cardiogenic acute lung edema Beneficial effects of positive pressure ventilation CPAP vs BiPAP vs Standard of Care Chronic/stable heart failure Cardio-respiratory interactions & BDS in chronic HF patients Potential benefits of positive pressure ventilation

3 NIV has been has an important clinical role in both acute Increasing decompensate prevalence of chronic congestive kidney dysfunction HF & in chronic stable patients with BDS Non-Invasive Positive Pressure Ventilation Definition Basic principles & practical setup and hints Acute/decompensated heart failure Basic pathophysiology of cardiogenic acute lung edema Beneficial effects of positive pressure ventilation CPAP vs BiPAP vs Standard of Care Chronic/stable heart failure Cardio-respiratory interactions & BDS in chronic HF patients Potential benefits of positive pressure ventilation

4 Non-Invaive positive pressure ventilation (NPPV) is a way of assuring positive pressure in the airways throughout Increasing prevalence of chronic kidney dysfunction the entire respiratory cycle without intubation NIV AVOIDS the risks associated with ETI Trauma to the oro-pharynx and airway Excessive hypotension Arrythmia Inability to cough: accumulation of respiratory debris Nosocomial pneumonia Dysphonia, granuloma formation Increased hospital stay and costs Increased mortality

5 Non-Invaive positive pressure ventilation (NPPV) is a way of assuring positive pressure in the airways throughout Increasing prevalence of chronic kidney dysfunction the entire respiratory cycle without intubation

6 NPPV is not a new concept: it s use began during the first half of the 20 th century Poulton EP, Lancet 1936;228:

7 Non-Invaive positive pressure ventilation (NPPV) is a way of assuring positive pressure in the airways throughout Increasing prevalence of chronic kidney dysfunction the entire respiratory cycle without intubation Continuous Positive Airway Pressure (CPAP) Bi-level Positive Airway Pressure (IPAP + EPAP) Pressure regulated volume ventilation

8 Non-Invaive positive pressure ventilation (NPPV) is a way of assuring positive pressure in the airways throughout Increasing prevalence of chronic kidney dysfunction the entire respiratory cycle without intubation Continuous Positive Airway Pressure The most commonly used method: minimal training Relatively simple, portable devices Not true mechanical ventilation, as inspiratory effort depends entirely on the patient Positive pressure produced by a unidirectional valve: may use a fan or O2 (Boussignac) to generate flow/pressure Mixture in the facial mask may facilitate re-inspiration of CO2 (caution in hypercapneic pts!)

9 Non-Invaive positive pressure ventilation (NPPV) is a way of assuring positive pressure in the airways throughout Increasing prevalence of chronic kidney dysfunction the entire respiratory cycle without intubation Bi-level Positive Airway Pressure Less commonly used: requires more extensive training, team experience & more expensive equipment Usually employs typical ICU ventilators Helps inspiratory effort with patient triggered preset pressure during inspiration (IPAP) Theoretically more physiological Allows higher tidal volumes (potential advantage in hypercapneic/acidotic pts!)

10 NIV has been has an important clinical role in both acute Increasing decompensate prevalence of chronic congestive kidney dysfunction HF & in chronic stable patients with BDS Non-Invasive Positive Pressure Ventilation Definition Basic principles & practical setup and hints Acute/decompensated heart failure Basic pathophysiology of cardiogenic acute lung edema Beneficial effects of positive pressure ventilation CPAP vs BiPAP vs Standard of care Chronic/stable heart failure Cardio-respiratory interactions & BDS in chronic HF patients Potential benefits of positive pressure ventilation

11

12 Pulmonary Edema is a frequent manifestation of Heart Increasing Failure prevalence & halves of chronic kidney a dire dysfunction prognosis 30 European countries; 133 centres; 3580 pts Available at

13 Positive pressure improves ventilation by counteracting the pathophysiological pathways Increasing prevalence of chronic kidney dysfunction in acute cardiogenic lung edema Opens flooded & collapsed alveoli Increases functional residual capacity Decreases dead space Decreases intra-pulmonary shunt Increases tidal volume

14 Positive pressure improves ventilation by counteracting the pathophysiological pathways Increasing prevalence of chronic kidney dysfunction in acute cardiogenic lung edema Randomised controlled trial of continuous positive airway pressure and standard oxygen therapy in acute pulmonary oedema; effects on plasma brain natriuretic peptide concentrations. CPAP O 2 Kelly et al. Eur Heart J 2002;23:

15 Positive pressure improves ventilation by counteracting the pathophysiological pathways Increasing prevalence of chronic kidney dysfunction in acute cardiogenic lung edema

16 Positive pressure improves ventilation by counteracting the pathophysiological pathways Increasing prevalence of chronic kidney dysfunction in acute cardiogenic lung edema Raposo L, Rev Port Cardiol, 2003; 22 (Supl III): III-102 (Abstract)

17 Positive pressure ventilation has favorable effects on the loading conditions Increasing prevalence of chronic kidney dysfunction of the failing Left Ventricle

18 Evidence from RCTs and Meta-analysis strongly favors the use of NPPV for the Increasing prevalence of chronic kidney dysfunction treatment of acute decompensated HF/APE 23 trials

19 Despite theoretical advantages, overall, BiPAP does not seem to bee superior to CPAP Critical Care 2006, 10:R69 (doi: /cc4905) Available at:

20 Despite theoretical advantages, BiPAP dit not prove to be superior to CPAP in hypercapneic patients Critical Care 2006, 10:R69 (doi: /cc4905) Available at:

21 The largest RCT to date, failed to show a significant reduction in mortality with either method of NPPV vs standard medical care Multicenter, open, prospective, RCT Standard O 2 therapy CPAP (5-15 cm H 2 0) NIPPV (IPAP 8-20 cm H 2 O / EPAP 4-10 cm H 2 O) N=1609 pts

22 Increasing prevalence of chronic kidney dysfunction

23 Despite guideline recommendation NPPV use in the management of APE is heterogeneous records, with 114,756 (78%) cases of ADHF admitted from the ED Ventilation in 2,430 pts (6.5%) - 1,760 (72.4%) NIV & 670 (27.6%) ETI without an NIV trial. 1,688 (95.9% of NIV pts) managed only by NIV (NIV success) 72 (4.1% of NIV) failed NIV and subsequently received ETI (NIV failure).

24 Despite guideline recommendation NPPV use in the management Increasing prevalence of chronic APE kidney is heterogeneous dysfunction ~20% NPPV Available at

25 When to use & how to do it? Indications for Noninvasive Ventilation Indications Inadequate response to initial standard therapy At risk for endotracheal intubation Respiratory rate 30 Persistent 02 saturation 90% or PaO2/FiO2<200 on >4 L/min oxygen Mild hypercapnia (CO2<45 mmhg) or acidosis (ph<7.3) - preferably IPAP? Sense of respiratory muscle fatigue Contraindications Lack of training Apnea & Hemodynamic instability Inability to protect the airway and Uncontrollable vomiting Abnormal facial anatomy Recent GI or upper airway surgery (< 7 days) Altered mental status or uncooperative and inability to tolerate the mask Need for immediate ETI due to worsening instability Very severe obstructive airway disease

26 When to use & how to do it? Noninvasive Ventilation Settings Continuous Positive Airway Pressure Start with cm H 2 0 Increase in increments of 2 cm H 2 0, as tolerated and indicated FiO 2 >40% Bi-Level Positive Airway Pressure / Noninvasive Pressure Support Ventilation Initial inspiratory pressure of 8 10 cm H 2 0 Increase in increments of 2 4 cm H 2 0 (Max ~20 cm H 2 0) aiming at TV>7ml/Kg Initial expiratory pressure of ~4-5 cm H 2 0 Maximum inspiratory pressure is 24 cm H 2 0 and expiratory pressure 20 cm H 2 0 FiO 2 >40%

27 When to use & how to do it? Improvement Criteria Monitoring and withdraw Heart rate <100 bpm Respiratory rate <30/min Ability to maintain SpO 2 >90% on spontaneous breathing FiO 2 <40-50% (mask) Improvement in dyspneia, without use of ancillary muscles Factors associated with the success of noninvasive ventilation Patient-ventilator synchrony /acceptance of the technique by the patient Glasgow coma score over 9 & APACHE II score < 21. Few secretions No pneumonia baseline Hypercapnia and initial ph above 7.1 Good response in the 1st hour of T/ with correction of acidosis & hypoxemia Arterial hypertension at baseline

28 NIV has been has an important clinical role in both acute Increasing decompensate prevalence of chronic congestive kidney dysfunction HF & in chronic stable patients with BDS Non-Invasive Positive Pressure Ventilation Definition Basic principles & practical setup and hints Acute/decompensated heart failure Basic pathophysiology of cardiogenic acute lung edema Beneficial effects of positive pressure ventilation CPAP vs BiPAP vs Standard of care Chronic/stable heart failure Cardio-respiratory interactions & BDS in chronic HF patients Potential benefits of positive pressure ventilation

29 Sleep Disordered Breathing (SDB) is highly prevalent in chronic HF patients and is associated with poor QOL and increased mortality 80% prevalence

30 Sleep Disordered Breathing (SDB) is highly prevalent in chronic HF patients and is associated with poor QOL and increased mortality 296 CHF patients Median LVEF=33% In-lab polysomnography Impact of CPAP Treatment Adjusted HR 2.9 (95% CI ; p=0.0023)

31 In Chronic HF patients with SDB, treatment effect of nocturnal CPAP is higher in those with the central type of sleep apnea The CANPAP Trial 258 HF patients with Central sleep apnea (nº episodes of apnea/hypopnea 40±16 per hour of sleep) Ejection fraction 24.5±7.7% FUP 3 months Increase in the 6 min walk test distance Decrease in norepinephrine No benefit in hard clinical endpoints (mortality & transplant rate)

32 In Chronic HF patients with SDB, treatment effect of nocturnal CPAP is higher in those with the central type of sleep apnea The CANPAP Trial HR 0.37 (95% CI ; p=0.043) vs control (noncpap pts)

33 Conclusions & Take-Home messages NPPV provides excellent clinical results when proper patient selection is accounted for and treatment is initiated early in an adequate window of opportunity by an experienced team Aorta It can dramatically improve ventilation and cardiac performance (except in severe diastolic dysfunction, hypovolemia or severe LV systolic failure) NIV is associated with highly significant reductions in the need for ETI (up to 55%!) and may reduce early mortality Either technique appears equally effective, but CPAP is cheaper, easer to use and requires less training There is no clear cut evidence that NPSV actually increases the risk of new myocardial infarction, but caution is advised when treating acute MI or severe CAD patients (increase in LV transmural pressure.)

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