What is the relationship between Bi-level Positive Airway Pressure (BiPAP) therapy and heart failure?

From the Guidelines

BiPAP therapy is recommended for patients with acute heart failure and respiratory distress, as it can reduce the workload on the heart, improve oxygenation, and decrease the need for intubation. The European Society of Cardiology guidelines suggest that non-invasive positive pressure ventilation, including BiPAP, should be considered in patients with respiratory distress (respiratory rate >25 breaths/min, SpO2 <90%) without hypotension 1.

Key Considerations for BiPAP Therapy in Heart Failure

• BiPAP can reduce preload and afterload, decreasing the workload on the failing heart
• Typical starting settings for BiPAP are 10 cmH2O for inspiratory pressure (IPAP) and 5 cmH2O for expiratory pressure (EPAP), which can be titrated up as needed based on patient response
• Continuous monitoring of oxygen saturation, respiratory rate, and work of breathing is essential during BiPAP therapy
• BiPAP should be used alongside standard heart failure treatments, including diuretics, vasodilators, and other heart failure medications

Benefits of BiPAP Therapy

• Improves oxygenation and reduces the work of breathing
• Can prevent the need for intubation in acute heart failure patients
• May improve cardiac function, reduce hospitalizations, and potentially improve mortality outcomes in chronic heart failure patients with sleep-disordered breathing

Important Guidelines and Recommendations

• The 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure recommend non-invasive positive pressure ventilation, including BiPAP, for patients with respiratory distress 1
• The 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation recommend considering non-invasive positive pressure ventilation in patients with respiratory distress without hypotension 1

From the Research

Bipap and Heart Failure

• Non-invasive mechanical ventilation (NIMV) therapy, including bilevel positive airway pressure (BIPAP), is used in the treatment of heart failure (HF) to improve left ventricular functions and reduce intubation rate and short-term mortality 2.
• BIPAP therapy has been shown to eliminate central and obstructive apneas and Cheyne-Stokes respiration, and improve morbidity in patients with chronic HF 2.
• The use of BIPAP in HF patients has been found to improve exercise tolerance and dyspnea, with significant improvements in 6-min walk test distance and dyspnea scores compared to control groups 3.
• Non-invasive ventilation (NIV) with BIPAP has been found to be beneficial in acute heart failure (AHF) patients, with improvements in respiratory distress, reduction in need for intubation, and mortality 4, 5.
• The hyperacute effects of BIPAP NIV in AHF patients have been found to improve hemodynamic, respiratory, and microcirculation indexes, with significant improvements in arterial blood oxygenation, hemodynamics, and microcirculation perfusion 6.

Modes of Non-Invasive Ventilation

• There are several modes of NIV used in the treatment of HF, including:
  • Continuous positive airway pressure (CPAP)
  • Bilevel positive airway pressure (BIPAP)
  • Adaptive servo-ventilation (ASV)
• CPAP is a simpler technique that may be preferred in low-equipped areas, while BIPAP may be preferable in patients with significant hypercapnia 2, 5.

Indications and Practical Approach

• NIV is indicated as first-line therapy in acute cardiogenic pulmonary edema (ACPE) and may be considered in stable cardiogenic shock and AHF associated with chronic obstructive pulmonary disease (COPD) 4, 5.
• The correct selection of patients and interfaces, early application of the technique, and close monitoring are crucial for the success of NIV therapy in HF patients 5.