From the Guidelines
BiPAP is preferred over high flow nasal cannula in heart failure because it provides positive pressure during both inspiration and expiration, which directly addresses the pathophysiology of heart failure. BiPAP delivers inspiratory positive airway pressure (IPAP) of typically 10-20 cmH2O and expiratory positive airway pressure (EPAP) of 4-10 cmH2O, which reduces preload and afterload on the heart. This dual pressure support decreases the work of breathing, improves cardiac function by reducing venous return to the right heart, and helps clear pulmonary edema by pushing fluid from the alveoli back into the vasculature. Additionally, BiPAP improves oxygenation and ventilation simultaneously, addressing both hypoxemia and potential hypercapnia that can occur in acute heart failure.
According to the 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 1, non-invasive positive pressure ventilation (CPAP, BiPAP) should be considered in patients with respiratory distress and started as soon as possible to decrease respiratory distress and reduce the rate of mechanical endotracheal intubation. The guidelines also recommend monitoring of transcutaneous arterial oxygen saturation (SpO2) and measurement of blood pH and carbon dioxide tension in patients with acute pulmonary edema or previous history of COPD.
While high flow nasal cannula can provide some positive pressure and improve oxygenation, it cannot deliver the same level of pressure support as BiPAP, making it less effective for the significant respiratory distress and pulmonary congestion seen in decompensated heart failure. The American College of Physicians suggests that clinicians use high-flow nasal oxygen rather than noninvasive ventilation in hospitalized adults for the management of acute hypoxemic respiratory failure, but this recommendation is based on low-certainty evidence 1.
In contrast, the use of BiPAP in heart failure is supported by studies such as Masip et al 1, which showed that BiPAP reduced intubation rates and improved respiratory outcomes in patients with cardiogenic pulmonary edema. Therefore, BiPAP should be initiated promptly in heart failure patients with respiratory distress, with careful monitoring of vital signs, work of breathing, and blood gases to assess response to therapy.
From the Research
Comparison of BiPAP and HFNC in Heart Failure
- BiPAP is often used in heart failure due to its ability to provide both inspiratory and expiratory positive pressure, which can help reduce respiratory distress and improve oxygenation 2.
- HFNC, on the other hand, is a newer modality that has shown promise in cases of acute heart failure with less severe respiratory failure, as it can reduce cardiac preload and improve oxygenation 3, 4.
- A study comparing HFNC to noninvasive positive pressure ventilation (NPPV) in patients with heart failure after extubation found that HFNC was not inferior to NPPV for preventing extubation failure and reintubation 3.
- However, another study found that HFNC may not be as effective as BiPAP in improving right ventricular morphology and function in patients with acute-on-chronic respiratory failure and pulmonary hypertension 5.
Indications for BiPAP in Heart Failure
- BiPAP is indicated in patients with severe acute congestive heart failure, as it can decrease the intubation rate and improve cardiopulmonary parameters 2.
- BiPAP is also indicated in patients with heart failure associated with pulmonary disease, and may be considered after hemodynamic stabilization in patients with cardiogenic shock 6.
- The choice between BiPAP and HFNC may depend on the severity of respiratory failure and the patient's underlying condition, with BiPAP being preferred in more severe cases and HFNC being preferred in less severe cases 3, 4.
Outcomes of BiPAP and HFNC in Heart Failure
- Studies have shown that BiPAP can reduce the intubation rate and improve oxygenation in patients with heart failure, although the impact on mortality is less conclusive 6, 2.
- HFNC has also been shown to improve oxygenation and reduce reintubation rates in patients with heart failure, although its effectiveness may vary depending on the severity of respiratory failure 3, 5.
- Further studies are needed to fully compare the outcomes of BiPAP and HFNC in heart failure, and to determine the optimal choice of therapy for individual patients 3, 2.