Indications and Practical Approach to Non-invasive Ventilation in Acute Heart Failure

Josep Masip; W. Frank Peacock; Susanna Price; Louise Cullen; F. Javier Martin-Sanchez; Petar Seferovic; Alan S. Maisel; Oscar Miro; Gerasimos Filippatos; Christiaan Vrints; Michael Christ; Martin Cowie; Elke Platz; John McMurray; Salvatore DiSomma; Uwe Zeymer; Hector Bueno; Chris P. Gale; Maddalena Lettino; Mucio Tavares; Frank Ruschitzka; Alexandre Mebazaa; Veli-Pekka Harjola; Christian Mueller

Disclosures

Eur Heart J. 2018;39(1):17-25. 

In This Article

Abstract and Introduction

Abstract

In acute heart failure (AHF) syndromes significant respiratory failure (RF) is essentially seen in patients with acute cardiogenic pulmonary oedema (ACPE) or cardiogenic shock (CS). Non-invasive ventilation (NIV), the application of positive intrathoracic pressure through an interface, has shown to be useful in the treatment of moderate to severe RF in several scenarios. There are two main modalities of NIV: continuous positive airway pressure (CPAP) and pressure support ventilation (NIPSV) with positive end expiratory pressure. Appropriate equipment and experience is needed for NIPSV, whereas CPAP may be administered without a ventilator, not requiring special training. Both modalities have shown to be effective in ACPE, by a reduction of respiratory distress and the endotracheal intubation rate compared to conventional oxygen therapy, but the impact on mortality is less conclusive. Non-invasive ventilation is also indicated in patients with AHF associated to pulmonary disease and may be considered, after haemodynamic stabilization, in some patients with CS. There are no differences in the outcomes in the studies comparing both techniques, but CPAP is a simpler technique that may be preferred in low-equipped areas like the pre-hospital setting, while NIPSV may be preferable in patients with significant hypercapnia. The new modality 'high-flow nasal cannula' seems promising in cases of AHF with less severe RF. The correct selection of patients and interfaces, early application of the technique, the achievement of a good synchrony between patients and the ventilator avoiding excessive leakage, close monitoring, proactive management, and in some cases mild sedation, may warrant the success of the technique.

Introduction

Acute respiratory failure (RF), defined as fall in blood oxygen concentration (hypoxaemia) with or without hypercapnia, is one of the most important causes of emergency department presentation in adults. High-flow 'Venturi' masks and low-flow reservoir masks or thin nasal cannulas are the standard forms of conventional oxygen therapy (COT) to treat these patients. However, RF is not often fully compensated with COT and requires greater respiratory support. Traditionally, this was only provided by a ventilator, generating positive intrathoracic pressure (PIP) via endotracheal intubation (EI). Nevertheless, EI carries its own risks, and usually requires complete sedation and admission to a critical care area. Non-invasive ventilation (NIV) is a technique that emerged in the 1980's, that consists of applying positive pressure to conscious patients through different interfaces, it has been shown to be useful in acute RF, reducing the need for EI and decreasing its associated risk of infection, mainly ventilator-associated pneumonia.[1] Since its introduction, NIV has been extended to different areas of the hospital, the pre-hospital setting and even domiciliary care, while ventilation through EI has remained limited to critical units or the operating theatre. Non-invasive ventilation is indicated to treat RF in a range of different scenarios, including dysfunction of the nervous system, muscles, chest wall, airways, and lung parenchyma, such as acute heart failure (AHF).

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