How to Treat Respiratory Distress in Acute Decompensated Heart Failure Patients Without Using a Mask?

When it comes to treating patients with acute decompensated heart failure (ADHF), usually an exacerbation of congestive heart failure (CHF), non-invasive positive pressure ventilation (NiPPV) is often the go-to therapy. However, studies show that more than 30% of patients cannot tolerate NiPPV due to mask intolerance.[1] There is a multitude of strategies clinicians can employ to prevent NiPPV failure in mask-intolerant patients, though one of the best strategies may be to have the option of a mask-free interface for patients in undifferentiated respiratory distress.

The Efficacy of Mask-Free NIV for Spontaneously Breathing Patients
Vapotherm’s® high velocity therapy is a mask-free alternative to NiPPV for treating undifferentiated respiratory distress in adults presenting in the Emergency Department.[2] A multi-center, randomized, controlled, noninferiority trial found no difference in the efficacy between NiPPV and high velocity therapy in treating respiratory distress in this patient population. A recently published subgroup analysis of just the patients with a ADHF/CHF diagnosis at discharge found that there was no difference in the efficacy of treatment or risk for intubation between NiPPV and high velocity therapy.[3] However, the trial and analysis did find a difference in secondary outcomes as illustrated in Figure 1.

The Benefits of a Mask-Free Interface for Mask-Intolerant Patients

Figure 1: The Benefits of a Mask-Free Interface for Mask-Intolerant Patients – Selected Secondary Outcomes – monitoring need and technical difficulty had similar results. Used Doshi et al. High velocity therapy in the Treatment of Respiratory Failure, Ann of Emerg Med, 2017;1:11. (Adult, Multi, Clinical trial, Prospective, Randomized, Multi-Center, n=201)

When examining the secondary outcomes of the trial, NiPPV and high velocity therapy had similar results in terms of the need for monitoring and technical difficulty. However, high velocity therapy was rated as superior when it came to physicians’ perceptions of patient response, patient comfort, and simplicity of use. High velocity therapy’s mask-free interface may be one of the features contributing to these superior perceptions.

Why ADHF/CHF Patients May Especially Benefit from a Mask-Free Interface

The benefits of Mask-Free NIV for spontaneously breathing patients may be particularly pertinent for ADHF/CHF patients. In the aforementioned subgroup analysis, Haywood and colleagues posit the following about the possible importance of trying to avoid further agitating ADHF/CHF patients:

“A large contributor to the cardiopulmonary decompensation of patients in heart failure is increased catecholamine release which redistributes splanchnic blood flow. Many of our current therapies for acute treatment of this population are directed at countering this increased sympathetic surge. In many patients, a tight-fitting mask increases agitation. This may increase sympathetic tone, thereby counter acting our resuscitative efforts.”[2]

Experiences of Emergency Department Physicians

In a conversation with several Emergency Department physicians, the VP of Medical Affairs for Vapotherm asked them about their personal experiences using the technology on CHF patients. Their anecdotal reports are in line with the subgroup analysis findings regarding the effectiveness of the tool. You can watch the 3-minute excerpt of their conversation below.

While the subgroup analysis was not powered for a definitive conclusion, the results are interesting.  Despite these limitations, the authors conclude that the results of this analysis “provide permission to use HVNI in … patients presenting to the ED with respiratory failure secondary to ADHF that do not require emergent intubation.”[3]

Download the e-book on Mask-Free NIV for Spontaneously Breathing Patients

[1] Carron M. et al. Complications of non-invasive ventilation techniques: a comprehensive qualitative review of randomized trials. British Journal of Anaesthesia. 110(6):896-914. (2013)
[2] Doshi, Pratik et al. High-Velocity Nasal Insufflation in the Treatment of Respiratory Failure: A Randomized Clinical Trial. Annals of Emergency Medicine, 2018.
[3] Haywood, Steven T, Jessica S. Whittle, Leonithas I. Volakis, George Dungan II, Michael Bublewicz, Joseph Kearney, Terrell Ashe, Thomas L. Miller, Pratik Doshi. “HVNI vs NIPPV in the treatment of acute decompensated heart failure: Subgroup analysis of a multi-center trial in the ED.” The American Journal of Emergency Medicine, 2019.