Bi-Level Positive Airway Pressure Ventilation for Treating Heart Failure With Central Sleep Apnea That is Unresponsive to Continuous Positive Airway Pressure

Cardiovascular Center, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo 105-8470, Japan.
Circulation Journal (Impact Factor: 3.94). 08/2008; 72(7):1100-5. DOI: 10.1253/circj.72.1100
Source: PubMed


Cheyne-Stokes respiration with central sleep apnea (CSR-CSA) is associated with a poor prognosis in patients with heart failure (HF). However, some patients do not respond to continuous positive airway pressure (CPAP), so other therapeutic modalities should be considered, such as bi-level positive airway pressure (PAP), which also assists respiration and might be effective for such patients.
The 20 patients with HF because of left ventricular systolic dysfunction were assessed: 8 had ischemic etiology, and all had severe CSA according to the apnea - hypopnea index (AHI) determined by polysomnography. All diagnosed patients underwent repeat polysomnography using CPAP. The AHI improved significantly in 11 (AHI <15), but only slightly in 9, in whom the AHI remained high (>or=15). Bi-level PAP titration significantly improved the AHI in the latter group. Those who were unresponsive to CPAP had significantly lower PaCO(2), higher plasma brain natriuretic peptide (BNP), longer mean duration of CSR and fewer obstructive episodes than CPAP responders. After 6 months of positive airway support with either CPAP (n=9) or bi-level PAP (n=7), BNP levels significantly decreased and left ventricular ejection fraction significantly increased.
Bi-level PAP could be an effective alternative for patients with HF and pure CSR-CSA who are unresponsive to CPAP.

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    • "Moreover, four patients in this group died from worsening HF [47]. BIPAP treatment could be effective in patients with cardiac dysfunction/HF complicated with SDB [47] [48] [49] and should be considered a nonpharmacologic adjunct to conventional drug therapy. Adaptive servoventilation (ASV) is a new approach to treating CSA/CSR and involves providing patients a small but varying amount of ventilatory support. "
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    ABSTRACT: Sleep-disordered breathing (SDB) causes hypoxemia, negative intrathoracic pressure, and frequent arousal, contributing to increased cardiovascular disease mortality and morbidity. Obstructive sleep apnea syndrome (OSAS) is linked to hypertension, ischemic heart disease, and cardiac arrhythmias. Successful continuous positive airway pressure (CPAP) treatment has a beneficial effect on hypertension and improves the survival rate of patients with cardiovascular disease. Thus, long-term compliance with CPAP treatment may result in substantial blood pressure reduction in patients with resistant hypertension suffering from OSAS. Central sleep apnea and Cheyne-Stokes respiration occur in 30–50% of patients with heart failure (HF). Intermittent hypoxemia, nocturnal surges in sympathetic activity, and increased left ventricular preload and afterload due to negative intrathoracic pressure all lead to impaired cardiac function and poor life prognosis. SDB-related HF has been considered the potential therapeutic target. CPAP, nocturnal O2 therapy, and adaptive servoventilation minimize the effects of sleep apnea, thereby improving cardiac function, prognosis, and quality of life. Early diagnosis and treatment of SDB will yield better therapeutic outcomes for hypertension and HF.
    Full-text · Article · Feb 2013 · Pulmonary Medicine
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    • "Those who were unresponsive to CPAP had significantly lower PCO 2 , higher plasma brain natriuretic peptide (BNP), longer mean duration of CSR and fewer obstructive episodes than CPAP responders. Among these 11 patients, 7 were chronically treated with bi-level PAP for 6 months with improved LV ejection fraction [28]. Thus they concluded bi-level PAP could be an effective alternative for patients with heart failure and pure CSR-CSA who are unresponsive to CPAP. "
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    ABSTRACT: Sleep disordered breathing including obstructive sleep apnea (OSA) and central sleep apnea (CSA) with Cheyne-Stokes respiration (CSR) is often accompanied by heart failure. Treatment of OSA centered on continuous positive airway pressure (CPAP) is established. However, treatment of CSR-CSA is still controversial. Since CSR-CSA occurs as a consequence of heart failure, optimization of heart failure is essential to treat CSR-CSA. For treatment directed at CSR-CSA itself, a variety of treatment approaches including night oxygen therapy and noninvasive positive pressure ventilation have been applied. Among them, night oxygen therapy improves patients' symptoms, quality of life (QOL), and left ventricular function, but had yet been shown to improve clinical outcome. For CPAP, there are responders and non-responders and for responders CPAP can also improve survival. Adaptive servo-ventilation (ASV), which most effectively treats CSR-CSA, improves exercise capacity, QOL, and cardiac function. Recent reports suggested ASV may also prevent cardiac events in patients with heart failure. However, further studies are needed to conclude that this treatment improves patient survival.
    Preview · Article · Mar 2012 · Journal of Cardiology
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    ABSTRACT: Noninvasive ventilation (NIV) with CPAP has been used as treatment of heart failure (HF). However, there are scarcity evidences about the exact use of this method in exercise intolerance. The aim of this study was to proceed a critical analyses concerning the use of NIV on HF, owning to demonstrate the efficacy and safety of this method in this syndrome. A systematic computerized search was performed to localize randomized controlled trials about NIV effects on HF between 1999 and 2009. The results of the evidences showed on this search ratified the efficacy of NIV with acute HF, even if in chronic HF when it's associated with sleep apnea and in exercise tolerance. Therefore, it was observed an increase in exercise tolerance when these patients were submitted to NIV. Nevertheless, there is necessity of more studies with accurate methodology concerning the mechanisms of these effects and the use of BiPAP in patients with HF.
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