What are the recommended initial Non-Invasive Ventilation (NIV) settings for patients with heart failure?

Initial NIV Settings for Heart Failure Patients

Non-invasive positive pressure ventilation (CPAP or BiPAP) should be started with CPAP at 5-7.5 cmH2O and titrated up to 10 cmH2O, or with BiPAP using inspiratory pressure of 12 cmH2O and expiratory pressure of 6 cmH2O in patients with acute heart failure presenting with respiratory distress. 1

Indications for NIV in Heart Failure

• NIV should be considered in patients with respiratory distress (respiratory rate >25 breaths/min, SpO2 <90%) and started as soon as possible to decrease respiratory distress and reduce the rate of mechanical endotracheal intubation 1
• Primary indications include acute cardiogenic pulmonary edema, particularly when unresponsive to conventional oxygen therapy 1
• NIV is particularly beneficial in patients with heart failure who have concurrent hypercapnia 2
• NIV should be initiated promptly when oxygen therapy alone fails to correct hypoxemia (SpO2 <90% or PaO2 <60 mmHg) 1

Initial Settings Algorithm

For CPAP (Continuous Positive Airway Pressure):

• Start with PEEP of 5-7.5 cmH2O 1
• Titrate based on clinical response up to 10 cmH2O 1
• Initial FiO2 delivery should be 0.40 (40%) 1
• Duration: Typically 30 minutes per hour until dyspnea and oxygen saturation remain improved without CPAP 1

For BiPAP (Bilevel Positive Airway Pressure):

• Initial inspiratory positive airway pressure (IPAP): 12 cmH2O 3
• Initial expiratory positive airway pressure (EPAP): 6 cmH2O 3
• Adjust settings if necessary based on patient comfort and respiratory parameters 1
• Add supplemental oxygen if SpO2 remains <85% despite NIV 1

Monitoring and Adjustment

• Attach pulse oximeter to patient before and during NIV 1
• Monitor blood pressure regularly, especially in hypotensive patients, as NIV can further reduce blood pressure 1
• Perform clinical assessment and check arterial blood gases at 1-2 hours after initiation 1
• Adjust settings or oxygen as necessary based on clinical response and blood gas results 1
• Consider alternative management if PaCO2 and pH have deteriorated after 1-2 hours of NIV on optimal settings 1

Choice Between CPAP and BiPAP

• CPAP is simpler, requires less training, and is recommended as first-line therapy, particularly in pre-hospital or low-equipped areas 4, 2
• BiPAP (NIPSV) is equally effective and may be preferable in patients with:
  • Mild fatigue 2
  • Significant hypercapnia 2
  • Associated chronic obstructive pulmonary disease 4, 2

Practical Implementation Tips

• Select an appropriately sized mask to fit the patient 1
• Hold the mask in place for the first few minutes before securing with straps/headgear 1
• Reassess after a few minutes and adjust settings if necessary 1
• Instruct the patient on how to remove the mask and summon help if needed 1
• Consider high-flow nasal cannula as an alternative for patients who need prolonged ventilation or show poor tolerance to NIV 2

Cautions and Contraindications

• Use NIV with caution in hypotensive patients and those with cardiogenic shock 1
• Monitor blood pressure regularly during NIV treatment 1
• Contraindications include:
  • Patients who cannot cooperate (unconscious, severe cognitive impairment) 1
  • Immediate need for endotracheal intubation due to progressive life-threatening hypoxia 1
  • Caution in patients with severe obstructive airways disease 1

Expected Outcomes

• NIV rapidly improves respiratory distress and reduces the need for intubation in acute cardiogenic pulmonary edema 4
• Studies show improved exercise tolerance and reduced dyspnea with BiPAP in heart failure patients 3
• Even when NIV fails and intubation is required, starting with NIV appears to have better outcomes than immediate intubation 5

By following these guidelines for NIV settings in heart failure patients, clinicians can optimize respiratory support while minimizing complications and potentially avoiding the need for invasive mechanical ventilation.