Effect of Nasal Continuous Positive Airway Pressure on Cardiac Output and Oxygen Delivery in Patients with Congestive Heart Failure

doi:10.1378/chest.102.5.1397

Chest

Volume 102, Issue 5, November 1992, Pages 1397-1401

https://doi.org/10.1378/chest.102.5.1397 Get rights and content

We studied the acute hemodynamic effects of increasing nasal continuous positive airway pressure (CPAP) in 13 patients with acute decompensation of congestive heart failure. Heart rate, respiratory rate, pulmonary capillary wedge pressure, right atrial pressure, systemic blood pressure, and thermodilution cardiac outputs were measured at baseline, during, and after application of nasal CPAP at increasing pressures of 5, 10, and 15 cm H₂0. Cardiac index, stroke volume, and oxygen delivery were calculated. Based on a significant change in cardiac output greater than or equal to 400 ml, seven patients were classified as responders, whereas six patients were considered to be nonresponders. In responders, significant increases were noted in cardiac index (2.5 ± 0.7 to 2.9 ± 0.9 L/min/m²), stroke volume (49 ± 15 to 57 ± 16 ml), and oxygen delivery (10.3 ± 5.1 to 12.3 ± 6.0 ml/min/kg) without a change in pulmonary capillary wedge pressure. In contrast, the nonresponders showed no significant change in any of the hemodynamic parameters. Improvement in cardiac output could not be predicted by any of the baseline hemodynamic or clinical variables, nor was it related to random variations since all variables returned to baseline after cessation of CPAP. Increase in stroke volume without a change in pulmonary capillary wedge pressure (preload) suggests either improved inotropic function of the left ventricle or reduced left ventricular afterload with CPAP. Thus, CPAP may offer a new noninvasive adjunct to improving left ventricular function and augmenting cardiac performance in a subset of patients with congestive heart failure.

Section snippets

METHODS

We studied 13 consecutive patients who were admitted to the intensive care unit for acute exacerbation of chronic CHF. All patients exhibited clinical signs of severe CHF with dyspnea, orthopnea, elevated jugular venous pressure, a ventricular gallop, and a pulmonary capillary wedge pressure greater than 20 mm Hg. Patients were awake, alert, and able to assist in their medical care. The study was performed within 24 h of placement of the pulmonary artery catheter and at a time when the patients

RESULTS

Salient clinical characteristics, the etiology of the heart failure, highest level of CPAP tolerated, and vasoactive agents administered are shown in Table 1. The patients were separated into two groups based on the cardiac output response to CPAP. Seven patients responded (R) to CPAP with an increase of cardiac output of 400 ml or greater. Six patients had no response (NR) to CPAP. Hemodynamic measurements, cardiac output, and oxygen delivery obtained at baseline, highest CPAP level tolerated,

DISCUSSION

This study produced two major findings. The first important finding was that cardiac output increased by at least 400 ml in 7 of the 13 clinically stable patients with chronic CHF when treated with CPAP In contrast, six patients (nonresponders) did not have a change in hemodynamics with CPAP. We noted no difference in the baseline parameters distinguishing responders from nonresponders, although responders tended to have lower heart rates and higher ejection fractions than nonresponders.

The

ACKNOWLEDGMENTS

: The writers thank Wendi Nugent of the Sleep Disorders Center for her technical assistance with the nasal CPAP unit, and Janet Elashoff and Sara Shain for their assistance with the statistical analysis.

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Citation Excerpt :
However, future studies should use OEP technology along with pleural and abdominal pressure measurements in order to investigate the acute effect of the application of pNIV on the work of breathing and respiratory muscle function. Earlier studies have shown adverse effects of continuous NIV devices on central haemodynamic responses in healthy and diseased groups (Ambrosino and Nava, 1993; Baratz and Westbrook, 1992; Diaz and Iglesia, 1997; Montner and Greene, 1994; Naughton and Rahman, 1995; Philip-Joet and Paganelli, 1999; Valipour and Schneider, 2005). Our original study in patients with COPD showed no adverse effects of pNIV application, albeit in the setting of exercise where there are increasing demands on cardiac output (Vogiatzis and Chynkiamis, 2019).
VitaBreath is a portable, non-invasive ventilation device (pNIV) that relieves shortness of breath in COPD by delivering fixed inspiratory and expiratory positive airway pressures (IPAP/EPAP: 18/8 cmH₂O). Fixed pressures may cause circulatory compromise. We investigated the circulatory effects of pNIV during normal breathing (NB) and after Eucapnic Voluntary Hyperpnoea trials (EVH) sustained at 80% MVV. In a balanced order sequence, 10 healthy men performed four trials on one visit: 1-min of pNIV (intervention) or 1-min quiet breathing (QB) during NB; and 1-min pNIV (intervention) or 1-min QB during recovery from 3-min EVH. Compared to QB, pNIV application was associated with greater cardiac output (CO: 1.6 ± 1.9 L.min⁻¹; P = 0.03). One minute into recovery from EVH, pNIV caused greater CO (2.2 ± 1.6 L.min⁻¹; P = 0.01) compared to QB. Mean blood pressure was not different with pNIV compared to control. pNIV increased thoracoabdominal volumes and breathing frequency during NB and recovery from EVH. pNIV application does not induce adverse hemodynamic effects in healthy men.
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Whether bilevel positive airway pressure (BiPAP) is advantageous compared with continuous positive airway pressure (CPAP) in acute cardiogenic pulmonary edema (ACPO) remains uncertain. The aim of the meta-analysis was to assess potential beneficial and adverse effects of CPAP compared with BiPAP in patients with ACPO.
Randomized controlled trials comparing the treatment effects of BiPAP with CPAP were identified from electronic databases and reference lists from January 1966 to December 2012. Two reviewers independently assessed study quality. In trials that fulfilled inclusion criteria, we critically evaluate the evidence for the use of noninvasive ventilation on rates of hospital mortality, endotracheal intubation, myocardial infarction, and the length of hospital stay. Data were combined using Review Manager 4.3 (The Cochrane Collaboration, Oxford, UK). Both pooled effects and 95% confidence intervals (CIs) were calculated.
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There are no significant differences in clinical outcomes when comparing CPAP vs BiPAP. Based on the limited data available, our results suggest that there are no significant differences in clinical outcomes when comparing CPAP with BiPAP.
Firing patterns of muscle sympathetic neurons during short-term use of continuous positive airway pressure in healthy subjects and in chronic heart failure patients
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The current study tested the hypothesis that modification in central hemodynamics during short-term continuous positive airway pressure (CPAP) application was accompanied by altered firing patterns of sympathetic nerve activity in CHF patients and healthy subjects.
Muscle sympathetic nerve activity (MSNA), hemodynamic and ventilatory parameters were obtained from 8 healthy middle aged subjects and 7 CHF patients. Action potentials (APs) were extracted from MSNA neurograms, quantified as AP frequency and classified into different sized clusters. While on CPAP at 10 cm H₂O, multi-unit MSNA, AP frequency and mean burst area/min increased in healthy middle aged subjects (p < 0.05) whereas CPAP had no effect on these variables in CHF patients. In conclusion, the impact of CPAP on central hemodynamics in healthy individuals elicited a moderate activation of sympathetic neurons through increased AP firing frequency, whereas in CHF patients both hemodynamics and MSNA remained unaltered.

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This study was supported in part by grant 972-GI-1 from the American Heart Association.

Manuscript received January 6; revision accepted March 23.

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Chest

Clinical InvestigationsEffect of Nasal Continuous Positive Airway Pressure on Cardiac Output and Oxygen Delivery in Patients with Congestive Heart Failure

Section snippets

METHODS

RESULTS

DISCUSSION

ACKNOWLEDGMENTS

Am J Cardiol

Chest

Chest

Treatment of severe cardiogenic pulmonary edema with continuous positive airway pressure delivered by face mask

N Engl J Med

Cardiac performance in response to PEEP in patients with cardiac dysfunction

Crit Care Med

Influence of positive end-expiratory pressure on left ventricular performance

N Engl J Med

Effect of intrathoracic pressure on left ventricular performance

N Engl J Med

Augmentation of cardiac function by elevation of intrathoracic pressure

J Appl Physiol

Mechanisms of blood flow during cardiopulmonary resuscitation

Circulation

Cough induced cardiac compression

JAMA

Clinical Investigations
Effect of Nasal Continuous Positive Airway Pressure on Cardiac Output and Oxygen Delivery in Patients with Congestive Heart Failure