Original ArticleBi-level positive pressure ventilation and adaptive servo ventilation in patients with heart failure and Cheyne-Stokes respiration
Introduction
Sleep-related breathing disorders are effectively treated with positive pressure ventilation (PPV) therapy. Not only patients with obstructive sleep apnea (OSA) benefit from this therapy but also patients with central sleep-related breathing disorders. Central sleep-related breathing disorders and Cheyne-Stokes respiration (CSR) in particular are common in patients with heart failure. Approximately 40% of patients with an impaired left ventricular ejection fraction (LVEF) suffer from central sleep-related breathing disorders, which increases their mortality [1], [2], [3], [4].
To reduce mortality and improve quality of life, sleep-related breathing disorders should be treated in patients with heart failure. Oxygen therapy can reduce CSR to a limited extent only [5]. The application of respiratory stimulants, carbon dioxide and atrial overdrive pacing are further means of treatment. Continuous positive airway pressure (CPAP) has proven to reduce CSR [6], [7], [8] and to improve LVEF when controlled after 1–3 months [3], [9]. This beneficial effect has been shown in patients with chronic heart failure (CHF) and OSA as well [10], [11].
In contrast, the Canadian positive airway pressure (CANPAP) trial showed that conventional CPAP decreased AHI only by 50% and CPAP was only tolerated for 3.5 h/night [12]. When considering the CPAP responder with an AHI below 15/h, this treatment was effective in abolishing CSR and improving LVEF and transplant-free survival [8]. The CANPAP study did not demonstrate improvements in sleep quality nor in the number of nocturnal arousals. Due to this negative result and due to the persistent clinical need to effectively reduce central apneas and to improve patient comfort, the search for alternative treatment modes besides CPAP [13] motivated this study.
Bi-level PPV is an alternative ventilation mode for patients with impaired LVEF and CSR [14]. Similar to data with CPAP, a few studies using bi-level PPV indicated that this ventilation mode can effectively reduce CSR, improve sleep quality, and increase LVEF in CHF patients [15], [16], [17], [18]. With the new ventilation technique, adaptive servo ventilation (ASV), similar positive effects on CSR and sleep quality were reported [16], [19], [20]. Pepperell et al. [20] did not report an effect on LVEF after 1 month of ASV support in CHF patients with central sleep apnea, although a significant decrease in brain natriuretic peptide (BNP) was observed. In contrast, Philippe et al. [19] reported for the first time an increase of LVEF over a period of 6 months in their ASV group compared to CPAP treated CHF patients.
Still results are contradicting regarding cardiovascular outcome and sleep characteristics with ASV therapy. More specifically, there are very few studies using bi-level PPV in CHF patients. For a selected patient population with heart failure and severe LVEF impairment, without complaints about sleep-disordered breathing (SDB) we wanted to test the efficacy of two ventilation modes: bi-level PPV spontaneous/timed (S/T) and ASV on CSR, sleep quality, and LVEF.
Section snippets
Subjects
A total of 129 patients with stable, pharmacologically treated CHF (LVEF < 45%, New York heart association [NYHA] functional class II–III) were screened in order to detect CSR, using an ambulatory polygraph with oximetry, heart rate, oronasal airflow, snoring sounds, and abdominal respiratory effort (Embletta; Embla Systems, Denver, Co, USA). Visual evaluation revealed that 42 patients had CSR with a respiratory disturbance index (RDI) > 15/h, with less than 20% obstructive respiratory events.
Results
The study showed a significant reduction in CSR for all patients receiving either mode of therapy. Nevertheless, in five patients we detected persistent SDB (> 15/h) under therapy (3 VPAP, 2 ASV). Three patients demonstrated an appreciable decrease in CSAI, but ultimately were unable to achieve an efficient adaptation setting to the variable positive airway pressure (VPAP) therapy. One patient had a higher RDI after VPAP therapy than before. Results for breathing, oxygen saturation, and
Discussion
In a patient population, primarily with no complaint about SDB and with stable chronic heart failure with severe LVEF impairment, we first selected patients who had CSR. For this selection we used an ambulatory polygraph, which was acceptable to these patients, and then confirmed the diagnosis by cardiorespiratory polysomnography. In a 6-week treatment trial we found an increase in LVEF on the basis of effective PPV treatment of CSR using two titration nights in the sleep laboratory. These
Acknowledgement
This study was supported in part by an unrestricted grant from Resmed, Germany.
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