From the Guidelines
Non-invasive ventilation (NIV) is indicated in patients with acute heart failure who have respiratory distress, as it reduces respiratory distress and may decrease the intubation and mortality rates. The decision to initiate NIV should be based on the presence of signs of respiratory failure, including respiratory rate >25 breaths per minute, use of accessory muscles, PaO2 <60 mmHg, or SpO2 <90% despite supplemental oxygen 1.
Key Considerations
- NIV should be started as soon as possible in patients with acute pulmonary edema (APE) showing respiratory distress 1.
- The two main types of NIV used are Continuous Positive Airway Pressure (CPAP) and Bilevel Positive Airway Pressure (BiPAP) 1.
- NIV works by reducing preload and afterload, improving cardiac function, reducing work of breathing, and enhancing oxygenation.
- NIV should be applied early in the course of decompensation, with close monitoring of vital signs, work of breathing, and blood gases.
Important Details
- Contraindications for NIV include respiratory arrest, hemodynamic instability, facial trauma, recent upper airway or esophageal surgery, and inability to protect the airway.
- NIV should be used alongside appropriate heart failure medications, including diuretics, vasodilators, and inotropes as indicated.
- The most recent and highest quality study, published in 2015, supports the use of NIV in patients with acute heart failure and respiratory distress 1.
Monitoring and Management
- Patients on NIV should be closely monitored for signs of improvement or deterioration, including vital signs, work of breathing, and blood gases.
- The treatment should be carried out in an environment with safe staffing levels and by nurses with specialist knowledge and skills to limit the risk of adverse events 1.
From the Research
Indications for Noninvasive Ventilation (NIV) in Heart Failure
- Acute cardiogenic pulmonary edema (ACPE) is a primary indication for NIV in heart failure patients, as it can rapidly improve respiratory distress and reduce the need for intubation and mortality 2, 3.
- NIV may also be considered in patients with acute heart failure (AHF) associated with pulmonary disease, such as chronic obstructive pulmonary disease (COPD) 2, 3.
- In cases of cardiogenic shock, NIV may be used after hemodynamic stabilization 2, 3.
- NIV can provide favorable physiologic benefits, including improving oxygenation, respiratory mechanics, and pulmonary and systemic hemodynamics 4.
Types of NIV and Their Applications
- Continuous positive airway pressure (CPAP) is a simpler technique that may be preferred in low-equipped areas, such as pre-hospital settings 2, 3.
- Noninvasive pressure support ventilation (NIPSV) with positive end-expiratory pressure may be preferable in patients with significant hypercapnia or mild fatigue 2, 3.
- High-flow nasal cannula is a promising modality for cases of AHF with less severe respiratory failure 3.
- Bilevel positive airway pressure (BiPAP) ventilation can rapidly improve hemodynamic, arterial blood gas, and microcirculation indexes in patients with AHF and left ventricular systolic dysfunction 5.
Outcomes and Benefits of NIV in Heart Failure
- NIV has been shown to reduce the intubation rate and improve clinical symptoms, resulting in good quality of life and mortality 4, 6.
- A successful trial of NIV is associated with improved outcomes in patients with acute decompensated heart failure (ADHF) 6.
- NIV may not harm patients and can be a reasonable treatment option, even if endotracheal intubation is eventually required 6.