Does nocturnal Bi-Level Positive Airway Pressure (BiPAP) improve outcomes in patients with heart failure?

From the Guidelines

Nocturnal Bi-Level Positive Airway Pressure (BiPAP) therapy can be considered in patients with heart failure, particularly those with respiratory distress, to decrease respiratory distress and reduce the rate of mechanical endotracheal intubation. BiPAP helps reduce the work of breathing, improves oxygenation, and decreases cardiac preload and afterload, which can benefit heart failure patients 1. The 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure recommend non-invasive positive pressure ventilation, including BiPAP, in patients with respiratory distress (respiratory rate >25 breaths/min, SpO2 <90%) 1.

Key Considerations

• BiPAP should be used with caution in hypotensive patients, as it can reduce blood pressure 1.
• The therapy is most beneficial for heart failure patients with sleep apnea, pulmonary congestion, or those with elevated BNP levels despite optimal medical therapy.
• Patients may need time to adjust to the mask and pressure settings, so starting with lower pressures and gradually increasing them can improve adherence.
• Regular follow-up with healthcare providers is essential to monitor progress and adjust settings as needed.

Pressure Settings

• Typically, patients start with inspiratory pressures of 8-12 cmH2O and expiratory pressures of 4-6 cmH2O.
• Pressure settings should be individualized based on the patient's condition.

Monitoring

• Transcutaneous arterial oxygen saturation (SpO2) should be monitored 1.
• Blood pH and carbon dioxide tension (possibly including lactate) should be considered, especially in patients with acute pulmonary oedema or previous history of COPD 1.

From the Research

Nocturnal Bi-Level Positive Airway Pressure (BiPAP) in Heart Failure

• The use of nocturnal Bi-Level Positive Airway Pressure (BiPAP) in patients with heart failure is not extensively studied in the provided evidence, with most studies focusing on Continuous Positive Airway Pressure (CPAP) and Adaptive Servo-Ventilation (ASV) 2, 3, 4, 5, 6.
• BiPAP may be as effective as CPAP in treating Sleep Disordered Breathing (SDB) and may be preferable over CPAP in patients who experience expiratory pressure discomfort 2.
• However, there is limited evidence on the specific use of BiPAP in heart failure patients, and its effects on outcomes such as mortality, hospitalization, and quality of life are not well established.

Comparison with Other Therapies

• CPAP is the major treatment for SDB in heart failure, especially if obstructive rather than central sleep apnea (CSA) predominates 2, 5.
• Adaptive Servo-Ventilation (ASV) may be useful in congestive heart failure patients if CPAP is ineffective, but its use has been associated with increased mortality in some studies 3, 4, 6.
• Other therapies, such as nocturnal oxygen, CO(2) administration, theophylline, and acetazolamide, have been proposed for SDB in congestive heart failure, but most have not been systematically studied in outcome-based prospective randomized trials 2.

Clinical Implications

• The management of SDB in patients with heart failure remains uncertain, and significant questions persist regarding the optimal treatment approach 4, 6.
• Cardiologists should have a high index of suspicion for sleep-disordered breathing in those with heart failure and work closely with sleep physicians to optimize patient management 6.
• Further research is needed to clarify the therapeutic rationale for the treatment of CSA in HF and to identify a treatment modality that increases cardiovascular survival in patients with SDB and heart failure 4, 6.