REUNIO CONJUNTA DOS GRUPOS DE ESTUDO

DE CUIDADOS INTENSIVOS CARDACOS E DE

FISIOPATOLOGIA DO ESFORO E
REABILITAO CARDACA
OLHO | 27 e 28 de Janeiro 2012

Non-Invasive Positive Pressure

Ventilation in Heart Failure Patients:
For Who, Wy & When?
Quais os doentes com insuficincia cardaca
que beneficiam de ventilao no-invasiva?
Luis Raposo
UNICARV | Hospit al de Sant a Cruz | CHLO

NIV has been has an important clinical role in

both acute
decompensate
HF & in
Increasing
prevalence of chroniccongestive
kidney dysfunction
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

NIV has been has an important clinical role in

both acute
decompensate
HF & in
Increasing
prevalence of chroniccongestive
kidney dysfunction
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

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

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

NPPV is not a new concept: its use began

during the first half of the 20th century

Poulton EP, Lancet 1936;228:981-983

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

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!)

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!)

NIV has been has an important clinical role in

both acute
decompensate
HF & in
Increasing
prevalence of chroniccongestive
kidney dysfunction
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

Pulmonary Edema is a frequent manifestation

Increasing
prevalence
of chronic kidney
dysfunction
of Heart
Failure
& halves
a dire
prognosis

30 European countries;
133 centres;
3580 pts

Available at
http://www.escardio.org/guidelines-surveys/ehs/heart-failure/Documents/EHS_HFII_MainPublication.pdf

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

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
O2

Kelly et al. Eur Heart J 2002;23:1379-1386

Positive pressure improves ventilation by

counteracting the pathophysiological pathways
Increasing prevalence of chronic kidney dysfunction
in acute cardiogenic lung edema

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)

Positive pressure ventilation has

favorable
effects on the loading conditions
Increasing prevalence of chronic kidney dysfunction
of the failing Left Ventricle

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
1985-2003

Despite theoretical advantages, overall, BiPAP

does not seem to bee superior to CPAP

Critical Care 2006, 10:R69 (doi:10.1186/cc4905)

Available at: http://ccforum.com/content/10/2/R69

Despite theoretical advantages, BiPAP dit not prove

to be superior to CPAP in hypercapneic patients

Critical Care 2006, 10:R69 (doi:10.1186/cc4905)

Available at: http://ccforum.com/content/10/2/R69

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 O2 therapy
CPAP (5-15 cm H20)
NIPPV (IPAP 8-20 cm H2O / EPAP 4-10 cm H2O)
N=1609 pts

Increasing prevalence of chronic kidney dysfunction

Despite guideline recommendation NPPV use

in the management of APE is heterogeneous

147.362 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).

Despite guideline recommendation NPPV use

Increasing prevalence of
of chronic
dysfunction
in the management
APE kidney
is heterogeneous

~20% NPPV

Available at
http://www.escardio.org/guidelines-surveys/ehs/heart-failure/Documents/EHS_HFII_MainPublication.pdf

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

When to use & how to do it?

Noninvasive Ventilation Settings
Continuous Positive Airway Pressure
Start with 5-7.5 cm H20
Increase in increments of 2 cm H20, as tolerated and indicated
FiO2 >40%
Bi-Level Positive Airway Pressure / Noninvasive Pressure Support Ventilation

Initial inspiratory pressure of 810 cm H20

Increase in increments of 24 cm H20 (Max ~20 cm H20) aiming at TV>7ml/Kg
Initial expiratory pressure of ~4-5 cm H20
Maximum inspiratory pressure is 24 cm H20 and expiratory pressure 20 cm H20
FiO2 >40%

When to use & how to do it?

Monitoring and withdraw
Improvement Criteria
Heart rate <100 bpm
Respiratory rate <30/min
Ability to maintain SpO2>90% on spontaneous breathing FiO2 <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

NIV has been has an important clinical role in

both acute
decompensate
HF & in
Increasing
prevalence of chroniccongestive
kidney dysfunction
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

Sleep Disordered Breathing (SDB) is highly

prevalent in chronic HF patients and is associated
with poor QOL and increased mortality

80% prevalence

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 1.1-3-5; p=0.0023)

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 (n episodes of apnea/hypopnea 4016 per hour of sleep)
Ejection fraction 24.57.7%
FUP 3 months

Increase in the 6 min walk test distance

Decrease in norepinephrine
No benefit in hard clinical endpoints (mortality & transplant rate)

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 0.14-0.96; p=0.043)

vs control (nonCPAP pts)

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.)