What is the efficacy of VAPS (Ventilatory Assistance by Pumping System) therapy in the treatment of central sleep apnea?

Efficacy of VAPS Therapy in Treatment of Central Sleep Apnea

VAPS (Ventilatory Assistance by Pumping System) therapy, also known as Adaptive Servo-Ventilation (ASV), should NOT be used for central sleep apnea in patients with heart failure with reduced ejection fraction (≤45%) due to increased mortality risk, but may be considered in other forms of central sleep apnea after careful patient selection. 1, 2

Treatment Recommendations Based on CSA Etiology

Heart Failure-Related Central Sleep Apnea

• ASV/VAPS is contraindicated in patients with heart failure with reduced ejection fraction (HFrEF) ≤45% and moderate-to-severe CSA due to increased cardiovascular mortality demonstrated in the SERVE-HF trial 1, 2
• For HFrEF patients with CSA, CPAP or low-flow oxygen should be used instead of ASV/VAPS 2, 3
• CPAP has been shown to reduce AHI to fewer than 15 events/hour in approximately 45% of patients with CSA associated with heart failure 3
• In patients with heart failure and preserved ejection fraction (>45%), ASV may be considered if CPAP fails, with close monitoring 2

Non-Heart Failure Central Sleep Apnea

• For primary CSA, PAP therapy (including VAPS/ASV) may be considered as a treatment option 4, 5
• For CSA due to high-altitude periodic breathing, descent from altitude or supplemental oxygen is recommended over ventilatory support 4
• For CSA due to opioid use, if discontinuation is not feasible, a trial of CPAP should be attempted first, followed by ASV if CPAP fails 4

Treatment Algorithm for Central Sleep Apnea

1. First-line therapy: CPAP trial (42.2% response rate in mixed CSA population) 6
2. Second-line options if CPAP fails:
   • CPAP + supplemental oxygen (20.3% response rate) 6
   • BiPAP therapy (28.1% response rate) 6
   • ASV/VAPS (only in non-HFrEF patients) 2, 3

Efficacy of Different Therapies

• CPAP: Most effective for CSA in patients with heart failure and ischemic heart disease 6
• BiPAP: Particularly effective for CSA in patients with history of opioid use 6
• ASV/VAPS: Effective for normalizing AHI in CSA with normocapnia and ventilatory instability, but contraindicated in HFrEF 7, 1
• Supplemental oxygen: May be effective as an adjunct therapy or in specific CSA subtypes 3, 8

Important Considerations and Cautions

• ASV/VAPS therapy has been shown to increase all-cause and cardiovascular mortality in HFrEF patients despite reducing AHI 1, 3
• Approximately 9.4% of CSA patients (particularly those with both CHF and IHD) may be non-responsive to all PAP therapies 6
• Pharmacological options like acetazolamide have limited supporting evidence but may be considered in specific cases 5
• Transvenous phrenic nerve stimulation carries risk of serious adverse effects in approximately 10% of patients 3

Monitoring and Follow-up

• Treatment with ASV/VAPS requires close monitoring of cardiac function and sleep parameters 2
• Regular assessment of treatment efficacy through follow-up sleep studies is recommended 7
• For patients with progressive conditions (like neuromuscular disease), more frequent monitoring may be necessary 4