Positive airway pressure therapy for heart failure

Table 1 Summary of equipped functions of each type/mode of positive airway pressure

	CPAP	Bi-level PAP	VAPS	ASV
Positive end-expiratory pressure	+	+	+	+
Pressure support during inspiration	-	+	+	+
Guarantee of tidal volume or minute ventilation	-	-	+	-
Servo-control of ventilation	-	-	-	+
Automated control of pressure level during expiration	+	-	-	+
Backup ventilation	-	±1	+2	+2

¹Bi-level PAP devices that are only capable of spontaneous mode cannot provide back-up ventilation;

²Most devices automatically provide a set backup ventilation rate based on their VAPS or ASV algorithm. ASV: Adaptive servo-ventilation; Bi-level PAP: Bi-level positive airway pressure; CPAP: Continuous positive airway pressure; VAPS: Volume assured pressure support.

Table 2 Adaptive servo-ventilation devices

	Volume-triggered ASV	Flow-triggered ASV
Manufacturer	ResMed	Philips-Respironics
Target	90% of previous average ventilation (moving time window)	90% of average peak flow (moving time window)
EPAP/EEP	EEP automatically adjusted between min and max (4-20 cm H2O) Cannot select auto EEP without PS	EPAP automatically adjusted between min and max (4-25 cm H2O)
IPAP	Max pressure up to 30 cm H2O IPAP changes within pre-set PS range from min (can be 0) to max Max PS can be limited by maximum pressure and current EEP	Max pressure up to 25 cm H2O IPAP changes within pre-set PS range from min (can be 0) to max (21 cm H2O) Max PS can be limited by pre-set maximum pressure and current EPAP level
Backup rate	Automatic	Auto rate
	15 ±α breaths/min	Fixed rate
Pressure wave form	Saw-tooth	Square shape
Inspiratory time	Automatic	Automatic in auto rate mode
		Set in manual rate mode

ASV: Adaptive servo-ventilation; EEP: End-expiratory pressure (i.e., = EPAP); EPAP: Expiratory positive airway pressure; IPAP: Inspiratory positive airway pressure; PS: Pressure support.

Table 3 Possible indication of each type/mode of positive airway pressure for each condition

	CPAP	Bi-level PAP	VAPS	ASV
Acute decompensated heart failure	o1	o	?2	?
Chronic HF with OSA	o	o	Δ3	Δ4
Chronic HF with CSA	Δ5	o	?	o
HF following acute decompensation	Δ6	o	?	Δ7
Chronic HF without SDB	×	?	?	Δ8
HF with hypoventilation (acute)	Δ9	o	o	×
HF with hypoventilation (chronic)	Δ9	o	o	?

¹Bi-level PAP with S-mode for accompanying OSA;

²Indicates that no clear data are available;

³Can be used if accompanied by hypoventilation;

⁴Can be used if Cheyne-Stokes respiration coexists;

⁵Can be used if CSA is alleviated;

⁶Can be used if OSA exists;

⁷Can be used if CSA exists;

⁸ASV may be useful for chronic HF patients with apnea-hypopnea index < 20 including those without SDB;

⁹Can be used if hypoventilation is associated with OSA. ASV: Adaptive servo-ventilation; Bi-level PAP: Bi-level positive airway pressure; CPAP: Continuous positive airway pressure; CSA: Central sleep apnea; HF: Heart failure; OSA: Obstructive sleep apnea; SDB: Sleep disordered breathing; VAPS: Volume assured pressure support.

Table 4 Recommendations for oxygen and bi-level positive airway pressure therapy for acute decompensated heart failure

Guidelines	Oxygen	PAP therapy
ACC/AHA (2009 updated)	To relieve symptoms related to hypoxemia: Class I, level C	NA
ACCF/AHA (2013)	NA	NA
HFSA (2010)	Hypoxia+: Class I, level C	Dyspnea+ or pulmonary edema+: Class I, level A
	Hypoxia-: Class III, level C
ESC (2012)	Hypoxemia+ (SaO2 < 90% or PaO2 < 60 mmHg): Class I, level C	Dyspnea+ or pulmonary edema+ or RR > 20/min: Class IIa, level B SBP < 85 mmHg: Class III
JCS (2011)	Hypoxia+ (to keep SaO2 > 95%, PaO2 > 80 mmHg): Class I, level C	Not responding to oxygen: Class I, level A

ACC: American college of cardiology; ACCF: American college of Cardiology foundation; AHA: American heart association; ESC: European Society of Cardiology; HFSA: Heart failure society of America; JCS: Japanese Cardiology Society; NA: Not available; PaO₂: Arterial partial pressure of oxygen; RR: Respiratory rate; SaO₂: Oxyhemoglobin saturation; SBP: Systolic blood pressure; PAP: Positive airway pressure.