What is the Optimal Strategy for Adaptive Servo-Ventilation Therapy?

Abstract

Clinical advantages in the adaptive servo-ventilation (ASV) therapy have been reported in selected heart failure patients with/without sleep-disorder breathing, whereas multicenter randomized control trials could not demonstrate such advantages. Considering this discrepancy, optimal patient selection and device setting may be a key for the successful ASV therapy. Hemodynamic and echocardiographic parameters indicating pulmonary congestion such as elevated pulmonary capillary wedge pressure were reported as predictors of good response to ASV therapy. Recently, parameters indicating right ventricular dysfunction also have been reported as good predictors. Optimal device setting with appropriate pressure setting during appropriate time may also be a key. Large-scale prospective trial with optimal patient selection and optimal device setting is warranted.

Pressure Ramp Testing for Optimization of End-Expiratory Pressure Settings in Adaptive Servo-Ventilation Therapy

“…Clinicians did their best to select appropriate patients for ASV therapy, using chest X-ray, echocardiography, and physical examination, as well as patient symptomology, to obtain evidence of systemic/pulmonary congestion. 1 ASV therapy was performed for the management of the chronic phase of CHF and our findings cannot be extrapolated to treatment of the acute phase. Given the small sample size, we used only age for background matching.…”

“…One of the primary components of successful ASV therapy is an increase in cardiac output, which may lead to downstream improvements in cardiac structure and function, in addition to lower heart failure readmission event rates. 1 ASV therapy with appropriate pressure settings should reduce both preload and afterload while increasing cardiac output. In the SERVE-HF trial, a relatively higher end-expiratory pressure setting to treat sleep disorder may have led to decreases in cardiac output, and subsequently higher rates of major adverse events.…”

“…device pressure setting may improve the efficacy of ASV therapy in patients with clinical heart failure, preventing low cardiac output. 1 We previously proposed a "pressure ramp test", during which hemodynamics are invasively measured at each endexpiratory pressure to determine an ideal device pressure setting. 5 One of the limitations of the pressure ramp test was the requirement for invasive hemodynamic assessment, which is challenging to perform routinely.…”

“…daptive servo-ventilation (ASV; AutoSet-CS; ResMed, Sydney, NSW, Australia) is non-invasive positive pressure ventilation therapy that stabilizes respiratory mechanics, suppresses sympathetic nervous system activity, and reduces pulmonary and systemic congestion by decreasing preload and afterload in patients with congestive heart failure (CHF), regardless of the presence of sleep-disordered breathing. 1 As a result, cardiac output increases, facilitating reverse remodeling and allowing for improved clinical outcomes over time. 2 However, in the SERVE-HF trial, ASV therapy was associated with an increased risk of cardiovascular death compared with the control arm.…”

“… 4 We hypothesized that optimizing the device pressure setting may improve the efficacy of ASV therapy in patients with clinical heart failure, preventing low cardiac output. 1 …”