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

Initial Non-Invasive Ventilation (NIV) Pressure Support Settings for Heart Failure

For patients with acute heart failure requiring NIV support, initial settings should include CPAP at 10 cmH2O or BiPAP with EPAP 5 cmH2O and inspiratory pressure between 12-25 cmH2O. 1

Indications for NIV in Heart Failure

• NIV is particularly indicated in cardiogenic pulmonary edema unresponsive to conventional oxygen therapy 2
• NIV should be used as first-line therapy in all patients with acute cardiogenic pulmonary edema (ACPE) 3
• NIV may be considered in stable cardiogenic shock after hemodynamic stabilization 4

Types of NIV Support for Heart Failure

CPAP (Continuous Positive Airway Pressure)

• Recommended as first-line therapy, particularly in pre-hospital or low-equipped areas 4
• Most common level of pressure is 10 cmH2O 1
• Simpler technique that may reduce preload and afterload, potentially increasing cardiac output 1
• Has demonstrated reduction in intubation rates and mortality 1

BiPAP/NIPSV (Non-Invasive Pressure Support Ventilation)

• Initial settings typically include:
  • EPAP (Expiratory Positive Airway Pressure): 5 cmH2O 1
  • Inspiratory pressure: between 12-25 cmH2O, though initially starting at lower levels 1
• Equally effective as CPAP in most scenarios 4
• Preferable in patients with mild fatigue or significant hypercapnia, including those with associated COPD 3, 4
• Requires more complex equipment and greater operator experience 1

Interface Selection

• Oronasal mask (full-face mask) is the most preferred interface for NIV in acute respiratory failure 5
• In the acute setting, a full-face mask should be used initially, changing to a nasal mask after 24 hours as the patient improves 2
• Helmet interface appears to be better tolerated for longer durations, resulting in lower NIV failure rates 6

Monitoring and Adjustment

• Essential to achieve good adaptation and synchronicity between patient and ventilator, reducing leakage to a minimum 1
• Close monitoring is required as deterioration can occur abruptly 2
• Complementary measures that may improve tolerance include:
  • Use of facial masks
  • High FiO2
  • Judicious sedation with opiates in selected cases 1, 5

Practical Considerations for Success

• Patient selection is critical - NIV is not indicated in patients with:
  • Impaired consciousness
  • Severe hypoxemia
  • Copious respiratory secretions 2
• Trigger sensitivity should be optimized - flow triggering is generally preferred over pressure triggering for better patient-ventilator synchrony 5
• For patients with significant hypercapnia, BiPAP should be preferred over CPAP 5
• High-flow nasal cannula may be an alternative for patients who need prolonged ventilation or show poor tolerance to conventional NIV 3

Common Pitfalls to Avoid

• Delaying intubation when NIV is failing - patients should be closely monitored for signs of NIV failure 2
• Using NIV in contraindicated scenarios (severe hypoxemia, impaired consciousness) 2
• Poor mask fit leading to excessive leakage and patient discomfort 6
• Inadequate pressure settings - insufficient pressure support will not reduce work of breathing effectively 1
• Neglecting patient comfort - discomfort is a major cause of NIV failure 6

Remember that NIV works best when initiated early in the course of respiratory failure, with appropriate settings and interfaces, and with close monitoring for response or deterioration 2.