Effects of Dynamic Bilevel Positive Airway Pressure Support on Central Sleep Apnea in Men With Heart Failure*
Department of Internal Medicine II, University of Regensburg, Franz-Josef-Straubeta-Allee 11, 93042 Regensburg, Germany. Chest
(Impact Factor: 7.48).
07/2008; 134(1):61-6. DOI: 10.1378/chest.07-1620
Treatment with continuous positive airway pressure (CPAP) improves cardiac function in chronic heart failure (CHF) patients with central sleep apnea (CSA)-Cheyne-Stokes respiration (CSR) by stabilizing ventilation, but frequently central apneas and hypopneas persist. Our objective was to test the hypothesis that flow-targeted dynamic bilevel positive airway pressure (BPAP) support (BiPAP autoSV; Respironics; Murrysville, PA) effectively suppresses CSR-CSA in CHF patients.
We studied 14 CHF patients with CSR-CSA (and residual CSA on positive airway pressure therapy) during 3 consecutive nights: (1) diagnostic polysomnography, (2) CPAP (n=10) or BPAP (n=4) titration, and (3) dynamic flow-targeted dynamic BPAP support with an expiratory positive airway pressure (EPAP) set to suppress obstructive respiratory events, and an inspiratory positive airway pressure (IPAP) dynamically ranging between 0 and 15 cm H2O above the EPAP.
CPAP or BPAP significantly reduced the apnea-hypopnea index (AHI) [mean+/-SD, 46+/-4 events/h to 22+/-4 events/h; p=0.001] compared to the first night without treatment. Flow-targeted dynamic BPAP support (mean EPAP, 6.5+/-1.7 cm H2O; maximal IPAP, 21.9+/-2.1 cm H2O) further reduced the AHI to 4+/-1/h of sleep compared to the untreated (p<0.001) and CPAP or BPAP night (p=0.002). After the first night of flow-targeted dynamic BPAP support, patients rated on an analog scale (range, 0 to 10) the treatment as comfortable (6.9+/-0.6), and the sleep quality as improved compared to previous nights (7.4+/-0.6).
Flow-targeted dynamic BPAP support effectively suppresses CSR-CSA in patients with CHF and is well tolerated.
Available from: Johan Verbraecken
- "In the up-to-date version of flow-targeted devices, the expiratory pressure is also adjusted automatically , with data showing a slightly better suppression of respiratory disturbances as compared with the algorithm with fixed expiratory positive airway pressure (EPAP). Since its introduction in 2001, many case series, case control series, and randomized controlled trials (RCT) have been published with considerable improvement in AHI, left ventricular ejection fraction (LVEF), and quality of life with volume-targeted           and flow-targeted devices       in patients with pure CSR. It was found that even patients with mild to moderate sleep disordered breathing (SDB) can demonstrate a significant improvement in LVEF  . "
Available from: Noriaki Takama
- "Adaptive servo-ventilation (ASV) was originally developed as a treatment modality for patients with central sleep apnea (CSA) and complex sleep apnea syndrome, but has also been used for obstructive sleep apnea      . Sleep disordered-breathing (SDB) is closely related to cardiovascular disease, including heart failure (HF)        , and is also closely related to the incidence of fatal cardiovascular events and mortality  . "
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ABSTRACT: It is unclear whether adaptive servo-ventilation (ASV) is safe and effective in patients with severe systolic heart failure (HF). Our aim in this study was to estimate the safety and efficacy of ASV therapy for patients with severe systolic HF.
Seventy-six HF patients (age: 69±12 years; 53 men), categorized as New York Heart Association (NYHA) Class II-IV, with left ventricular ejection fraction (LVEF) of <50%, received ASV therapy after optimal medical therapy to determine the safety and efficacy of ASV. Patients were divided into 2 groups based on their LVEF: group L (LVEF<30%; n=42) and group H (LVEF≥30%; n=34). After 6 months of ASV therapy, we compared the changes in LVEF, brain natriuretic peptide (BNP), and incidence of fatal cardiovascular events between the groups.
The groups differed significantly with respect to beta-blocker treatment before ASV therapy (p<0.0001). After 6 months of ASV therapy, LVEF and BNP levels had improved in both groups. In group L, LVEF had improved from 24.1±5.6% to 35.2±10.6% (p<0.0001) and BNP from 591 (273-993)pg/ml to 142 (39-325)pg/ml (p=0.002). Moreover, 1-year follow-up data showed a tendency toward improvement of NYHA classification in group L (group L: 50%; group H: 29%; p=0.07), and showed no significant difference with regard to fatal cardiovascular events between the 2 groups (group L: 11.9%; group H: 5.9%; p=0.36).
Our study demonstrated that ASV therapy is safe and effective for use in very severe systolic HF patients as well as in relatively mild systolic HF patients.
Available from: sciencedirect.com
- "Eight weeks was probably too short to show improvement in LV function for both treatment modalities. Another type of ASV (auto servo-ventilation) also effectively treats CSR-CSA . Kasai et al. reported the results of randomized study, J-ASV, of this device in comparison with CPAP in patients with chronic heart failure and coexisting CSR-CSA and OSA . "
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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.
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