CHEST Original Research

SLEEP MEDICINE

Effects of Dynamic Bilevel Positive

Airway Pressure Support on Central
Sleep Apnea in Men With Heart Failure*
Michael Arzt, MD; Roland Wensel, MD, PhD; Sylvia Montalvan, MD;
Thomas Schichtl, MD; Stephan Schroll, MD; Stephan Budweiser, MD;
Friedrich C. Blumberg, MD; Gunther A. J. Riegger, MD;
and Michael Pfeifer, MD

Background: Treatment with continuous positive airway pressure (CPAP) improves cardiac
function in chronic heart failure (CHF) patients with central sleep apnea (CSA)-Cheyne-Stokes
respiration (CSR) by stabilizing ventilation, but frequently central apneas and hypopneas persist.
Our objective was to test the hypothesis that flow-targeted dynamic bilevel positive airway
pressure (BPAP) support (BiPAP autoSV; Respironics; Murrysville, PA) effectively suppresses
CSR-CSA in CHF patients.
Methods: We studied 14 CHF patients with CSR-CSA (and residual CSA on positive airway pressure
therapy) during 3 consecutive nights: (1) diagnostic polysomnography, (2) CPAP (n 10) or BPAP
(n 4) titration, and (3) dynamic flow-targeted dynamic BPAP support with an expiratory positive
airway pressure (EPAP) set to suppress obstructive respiratory events, and an inspiratory positive
airway pressure (IPAP) dynamically ranging between 0 and 15 cm H2O above the EPAP.
Results: CPAP or BPAP significantly reduced the apnea-hypopnea index (AHI) [mean SD, 46 4
events/h to 22 4 events/h; p 0.001] compared to the first night without treatment. Flow-targeted
dynamic BPAP support (mean EPAP, 6.5 1.7 cm H2O; maximal IPAP, 21.9 2.1 cm H2O) further
reduced the AHI to 4 1/h of sleep compared to the untreated (p < 0.001) and CPAP or BPAP night
(p 0.002). After the first night of flow-targeted dynamic BPAP support, patients rated on an analog
scale (range, 0 to 10) the treatment as comfortable (6.9 0.6), and the sleep quality as improved
compared to previous nights (7.4 0.6).
Conclusion: Flow-targeted dynamic BPAP support effectively suppresses CSR-CSA in patients with
CHF and is well tolerated. (CHEST 2008; 134:61 66)

Key words: cardiology; central sleep apnea; ventilation

Abbreviations: AHI apnea-hypopnea index; BPAP bilevel positive airway pressure; CANPAP Canadian Trial of
Continuous Positive Airway Pressure for Patients with Central Sleep Apnea and Heart Failure; CHF chronic heart failure;
CPAP continuous positive airway pressure; CSA central sleep apnea; CSR Cheyne-Stokes respiration;
EPAP expiratory positive airway pressure; IPAP inspiratory positive airway pressure

C apnea
heyne-Stokes respiration (CSR)-central sleep
(CSA) is a common breathing disorder in
25 to 40% of patients with chronic heart failure
(CHF).13 In such patients, ventilation is destabilized
by a combination of high controller gain (increased
carbon dioxide responsiveness), hypocapnia resulting
from lung edema (high filling pressures), and a long
circulation time.37 CSR-CSA may contribute to
disease progression by exposing the failing ventricle
to intermittent hypoxia, arousals from sleep, and
surges in sympathetic nervous system activity and
BP.8 Ultimately, the presence of CSR-CSA and its
adverse effects confer an increased risk of mortality
For editorial comment see page 4
in CHF patients independent of underlying cardiac
function.9 11
Treatment of CSR-CSA with continuous positive
airway pressure (CPAP) has been demonstrated to

www.chestjournal.org CHEST / 134 / 1 / JULY, 2008 61

stabilize ventilation, attenuate sympathetic activa-
tion, and improve left ventricular function in patients
with CHF and CSR-CSA.1214 In the largest trial14 of
CPAP in CHF patients with CSR-CSA (Canadian
Trial of Continuous Positive Airway Pressure for
Patients With Central Sleep Apnea and Heart Fail-
ure [CANPAP]), the investigators found only a 50%
reduction in the apnea-hypopnea index (AHI) [ap-
neas and hypopneas per hour of sleep] and no
beneficial effects on prognosis. However, a stratified
analysis15 of the CANPAP trial demonstrated that
increases in left ventricular ejection fraction and
transplant-free survival were greater in those CHF
patients in whom CPAP suppressed CSR-CSA than
in the control group. These data suggest that a
reduction in AHI in response to CPAP is a predictor
of improved cardiovascular outcome in CHF pa-
tients with CSR-CSA.
As a large proportion of CPAP-treated CHF pa-
tients with CSR-CSA have residual apneas and hy-
popneas,14 and suppression of CSR-CSA appears to
be a possible mechanism by which positive airway
pressure support can improve cardiovascular out-
come in CHF patients,10,12,13,15,16 conventional
CPAP may not be the optimal therapeutic approach
in these patients. Therefore, devices that suppress
CSR-CSA more effectively are needed.
One such approach is flow-targeted dynamic bi-
level positive airway pressure (BPAP) support
(BiPAP autoSV; Respironics; Murrysville, PA),
which has been developed to normalize breathing in
patients with both obstructive sleep apnea and CSR-
CSA. The flow-targeted dynamic BPAP device pro-
vides a minimum expiratory positive airway pressure
(EPAP) to maintain upper-airway patency and elim-
inate obstructive apneas and hypopneas. In addition,
the device modulates inspiratory positive airway
pressure (IPAP) in order to maintain a target inspira-
tory airflow and eliminate central apneas and hypop-
neas. In this first clinical evaluation of flow-targeted
*From the Department of Internal Medicine II, Divisions of
Pneumology and Cardiology (Drs. Arzt, Wensel, Schroll, and
Riegger), University of Regensburg, Regensburg; the Center for
Pneumology (Drs. Schichtl, Montalvan, Budweiser, and Pfeifer),
Donaustauf Hospital, Donaustauf; and Prosper Hospital (Dr.
Blumberg), Recklinghausen, Germany.
Dr. Arzt received lecture fees from Respironics ($1,500 in 2007).
The other authors have no actual and potential conflicts of
interest to disclose.
Manuscript received July 2, 2007; revision accepted September
19, 2007.
Reproduction of this article is prohibited without written permission
from the American College of Chest Physicians (www.chestjournal.
org/misc/reprints.shtml).
Correspondence to: Michael Arzt, MD, Department of Internal
Medicine II, Pneumology, University of Regensburg, Franz-Josef-
Strau-Allee 11, 93042 Regensburg, Germany; e-mail: michael.
arzt@klinik.uni-regensburg.de
DOI: 10.1378/chest.07-1620
62
dynamic BPAP, our objective was to test the hypoth-
esis that it effectively suppresses CSR-CSA in CHF
patients in whom CSR-CSA persisted using conven-
tional CPAP or BPAP therapy.
Materials and Methods
Patients
Inclusion criteria were as follows: (1) age between 18 and 80
years; (2) CHF due to ischemic, hypertensive, or idiopathic
dilated cardiomyopathy with a left ventricular ejection fraction
45% as determined by resting echocardiography or by radio-
nuclidventriculography; (3) CSR-CSA (AHI 15/h, 80% cen-
tral apneas and hypopneas); and (4) a residual AHI 10/h during
a previous sleep study (not part of this trial) on conventional
CPAP or BPAP (without back-up rate) therapy. Patients who had
a residual AHI 10/h after 27 11 weeks of CPAP or BPAP
therapy were pooled in one group because the only mid-term
(cross-over) randomized trial17 comparing the effects of BPAP
and CPAP on CSA in CHF patients demonstrated that the
pretreatment AHI of 26.7 10.7/h was similar significantly
reduced by CPAP and BPAP to 7.7 5.6/h and 6.5 6.6/h,
respectively.
Exclusion criteria were as follows: (1) a history of unstable
angina, cardiac surgery, or documented myocardial infarction
within 3 months of entry into the study; (2) CHF due to valvular
heart disease; (3) daytime hypercapnia or the need for mechan-
ical ventilatory assistance for comorbid conditions; (4) important
COPD (FEV1 70% of predicted value or FEV1/FVC 60%);
(5) pregnancy; and (6) a history of pneumothorax and/or pneu-
momediastinum. We studied 14 consecutive sleep clinic patients
with CHF who met the inclusion and exclusion criteria above.
The investigation conforms with the principles outlined in the
Declaration of Helsinki. The patients gave written informed
consent to participate in this prospective study, which had been
approved by the Ethics of Human Research Committee of the
University of Regensburg.
Baseline Assessment
Demographic information, anthropometric measurements, and
status of CHF including objective evidence of systolic left
ventricular dysfunction and status of sleep-disordered breathing
(without positive pressure support) were assessed in all 14
eligible patients. During the first night of polysomnography, body
position, eye and leg movements, cardiotachography, nasobuccal
airflow (pressure cannula), thoracoabdominal movements (In-
ductotrace; Ambulatory Monitoring; Ardsley, NY), and pulse
oximetry were recorded (Alice 3.5; Respironics). Bedtime and
awakening time were at the discretion of each subject. Sleep
studies were scored by an experienced clinician who was blinded
to the applied treatment modality, using standard criteria.18
Apneas were defined as absence of tidal volume for 10 s
(measured reduction of airflow to 10% peak nominal air-
flow). Hypopneas were defined as a 50% reduction in air flow
from baseline for 10 s or with a discernable reduction in
airflow associated with a 4% oxygen desaturation or an arousal.
Apneas and hypopneas were classified obstructive if out-of-phase
thoracoabdominal motion or airflow limitation was present. The
AHI was defined as the mean number of apneas and hypopneas
per hour of sleep, and the oxygen desaturation index was defined
as the number of oxygen desaturations 4%/h of sleep.
Original Research
Principles of Operation of Flow-Targeted Dynamic BPAP
Flow-targeted dynamic BPAP provides positive airway pres-
sure support to sustain upper-airway patency. The EPAP is manu-
ally set to eliminate obstructive apnea/hypopnea during sleep,
which can be determined during conventional in-laboratory
polysomnography in CPAP mode. In this clinical evaluation, the
minimal IPAP is manually set at the determined EPAP level
(minimal IPAP EPAP). In addition, the flow-targeted dynamic
BPAP device modulates the IPAP above the EPAP as required to
maintain a target peak inspiratory airflow: when the device
detects normal breathing, flow-targeted dynamic BPAP operates
like conventional CPAP by providing the minimal IPAP
( EPAP); when the patient does not maintain the target peak
inspiratory airflow, the device increases the IPAP above the
EPAP up to a maximum IPAP, which can be set by the user (15
cm H2O above EPAP in this clinical evaluation). The device also
provides an automatic back-up rate should sustained apnea be
detected. In order to avoid hyperventilating the patient and to
promote spontaneous breathing, the target inspiratory flow is set
to below the mean inspiratory flow during spontaneous breathing
by the patient, and the timing of the back-up rate begins with
time delay and is set to a slower rate than the average respiratory
rate of the patient.
a repeated-measures analysis of variance with post hoc contrasts
by t tests was used. A two-sided p value 0.05 was considered to
indicate statistical significance.
Results
Patient Characteristics
Table 1 displays the baseline characteristics of the
14 male patients. They were mildly overweight and
had moderate-to-severe CHF due to ischemic, idio-
pathic, and hypertensive cardiomyopathy. All pa-
tients were receiving stable and optimal cardiac
medication for at least 4 weeks before entry into the
trial (Table 1). During the diagnostic polysomnogra-
phy, untreated patients had moderate-to-severe
CSR-CSA with 94% central apneas and frequent
mild oxygen desaturations (Table 2). Patients slept
for only 5.5 h, and sleep efficiency (total sleep
time/time in bed) was reduced (73 3%).

Protocol and Intervention

Effects of CPAP/BPAP and Flow-Targeted
Dynamic BPAP
After one diagnostic polysomnography, flow-targeted dynamic
BPAP was initiated during 2 consecutive nights with full poly-
Applied Pressures
somnography. Patients were blinded to the applied treatment During the CPAP/BPAP titration night, CPAP was
modality: during the first night, positive pressure support was
titrated using the flow-targeted dynamic BPAP device in CPAP
increased up to a mean maximum of 8.3 0.9 cm
(n 10) or BPAP (n 4) mode (depending of the treatment of H2O (n 10) and a mean maximum IPAP/EPAP of
sleep-disordered breathing the patients received before entry 13.5 3.0 cm H2O/7.6 1.7 cm H2O (n 4), and
into the study) in order to achieve maximal suppression of apneas patients spent at least 80% (81 14%) of the time
and hypopneas. Titration was started at 5.4 1.9 cm H2O receiving pressure settings optimally suppressing ap-
CPAP/EPAP pressure, which was increased in increments of 1 to
2.5 cm H2O until obstructive apneas and hypopneas were
neas and hypopneas. During the first night of flow-
optimally treated. Patients spent 81 14% of the time receiving
optimal positive airway pressure settings. During the second
consecutive night, flow-targeted dynamic BPAP was initiated;
EPAP was set to the optimal CPAP/EPAP levels determined Table 1Baseline Characteristics of Heart Failure
during the second (previous) night. IPAP dynamically ranged Patients*
from 0 to 15 cm H2O above EPAP. CPAP/BPAP and flow-
targeted dynamic BPAP were applied in a fixed order rather than Variables Data
a randomized order because the optimal EPAP had to be deter-
mined by retitration of CPAP or BPAP using a standardized protocol Patients, No. 14
to evaluate the optimal settings for CPAP, BPAP, and flow-targeted Age, yr 65 1
dynamic BPAP treatment. The morning following initiation of Male gender 14 (100)
flow-targeted dynamic BPAP, subjects completed a visual analog Body mass index, kg/m 28 1
scale of perceived treatment comfort and sleep quality. The analog Cause of heart failure
scale included two items: (1) how would you describe the comfort of Ischemic 6 (43)
the therapy you received through the night? Values ranged from 0 Nonischemic 8 (57)
(treatment was very uncomfortable) to 10 (treatment was very Medications
comfortable); and (2) how would you describe the quality of the rest Angiotensin-converting enzyme 13 (93)
you had last night? Values ranged from 0 (this was the worst night of inhibitors or angiotensin-1
sleep I have had in quite some time) and 10 (this was the best night inhibitors
of sleep I have had in quite some time). Loop diuretics 13 (93)
Spironolactone 7 (50)
Digoxin 3 (21)
Statistical Analysis -Blocker 14 (100)
Exercise capacity and cardiac function
All data were analyzed using statistical software (SPSS, version
NYHA functional class II 8 (57)
11.0; SPSS; Chicago, IL). Data are shown as mean SD. To
NYHA functional class III 6 (43)
assess differences in the number of respiratory events, oxygen
Left ventricular ejection fraction, % 27.4 2.2
saturation and polysomnographic measures of sleep quality be-
tween the sleep study at baseline, the CPAP/BPAP titration *Data are presented as mean SE or No. (%) unless otherwise
night, and the treatment night with flow-targeted dynamic BPAP, indicated. NYHA New York Heart Association.

www.chestjournal.org CHEST / 134 / 1 / JULY, 2008 63

 Table 2Short-term Effects of CPAP/BPAP and Flow-Targeted Dynamic BPAP in Patients With CHF and
CSR-CSA*

Flow-Directed p Value, Untreated p Value, CPAP/BPAP

CPAP/ Dynamic p Value, Untreated vs Flow-Directed vs Flow-Directed
Variables Untreated BPAP BPAP vs CPAP/BPAP Dynamic BPAP Dynamic BPAP

Breathing during sleep

AHI, events/h 46 4 22 4 41 0.001 0.001 0.002
Apnea index, events/h 34 5 16 3 10 0.003 0.001 0.012
Central apnea index, 32 5 15 3 10 0.006 0.001 0.014
events/h
Oxygen desaturation index, 42 4 22 6 21 0.005 0.001 0.005
events/h
Mean oxygen saturation, % 92.1 0.3 93.5 0.3 93.7 0.4 0.016 0.005 1.0
Minimum oxygen 80.2 1.6 79.9 3.9 92.1 0.9 1.0 0.016 0.015
saturation, %
Sleep characteristics
Arousal index, events/h 30 3 25 4 18 3 1.0 0.061 0.471
Total sleep time, min 331 17 371 12 371 15 0.187 0.181 1.0
Sleep efficiency, % 73 3 79 2 89 11 0.449 0.247 1.0
Slow-wave sleep, % 15.9 2.6 24.4 3.6 25.3 2.4 0.131 0.081 1.0
Rapid eye movement sleep, % 9.9 1.2 14.1 1.4 13.4 1.9 0.167 0.336 1.0
*Data are presented as mean SD.

targeted dynamic BPAP, maximum IPAP and mean
EPAP were set at 21.8 2.1 cm H2O and 6.5 1.7
cm H2O, respectively. The mean IPAP that was
actually applied by the flow-targeted dynamic BPAP
device was 8.0 2.4 cm H2O, significantly below the
maximum IPAP. No adverse clinical event occurred.
Breathing During Sleep
Both therapies, CPAP/BPAP and flow-targeted
dynamic BPAP, improved CSR-CSA compared to
the untreated night as indicated by a significant fall
in AHI, apnea index, central apnea index, and oxygen
desaturation index as well as a significant increase in
Sleep Quality and Treatment Comfort
With both CPAP/BPAP and flow-targeted dy-
namic BPAP therapies, reductions in CSR-CSA were
accompanied by trends (not statistically significant)
toward improvement in objective measures of sleep
quality and quantity (Table 2). With CPAP/BPAP
and flow-targeted dynamic BPAP, the arousal index
was reduced by 17% and 40%, respectively; patients
slept 40 min longer and had 8% and 18% higher
p<0.001
p<0.001 p=0.002
Apnea-hypopnea Index [no./h]

mean nocturnal oxygen saturation (Table 2). The 80

reduction of AHI by CPAP (n 10) and BPAP 70

(n 4) compared to the diagnostic polysomnogra- 60

phy was similar (53 18% vs 52 55%, p 0.723).
Flow-targeted dynamic BPAP reduced AHI, apnea
index, central apnea index, and oxygen desaturation
index significantly more than CPAP/BPAP therapy.
Minimal oxygen saturation was also significantly
higher with flow-targeted dynamic BPAP than with
CPAP/BPAP. In contrast to CPAP/BPAP, flow-
targeted dynamic BPAP further reduced the initial
AHI (range, 23 to 72/h of sleep) to below the
threshold of 15 apneas and hypopneas per hour of
sleep (which defined the presence of CSR-CSA in
this clinical evaluation) in all individuals (Fig 1). In
addition, the suppression of residual AHI by flow-
targeted dynamic BPAP compared to the CPAP
(n 10) or BPAP (n 4) night was similar
(85 11% vs 84 6%, p 0.751).
50
40
30
20
10
0
Untreated CPAP/BPAP BiPAP autoSV
Figure 1. Individual data of 14 patients with CHF and moderate-
to-severe CSR-CSA (mean AHI, 46 4/h of sleep) are displayed.
With CPAP or BPAP therapy, significant CSR-CSA persists in 50%
of CHF patients (mean AHI, 22 4/h of sleep). Flow-targeted
dynamic BPAP (BiPAP autoSV; Respironics) effectively suppresses
AHI (mean AHI, 4 1/h of sleep) in all individuals below the
threshold of 15 apneas and hypopneas per hour of sleep (dashed
line), which defined the presence of CSR-CSA in this clinical
evaluation. Patients who were treated with CPAP before the trial
and during the second night of the trial are depicted as . Patients
who were treated with BPAP before the trial and during the second
night of the trial are depicted as .

64 Original Research
 A 15/h of sleep). The CANPAP investigators14 found
Treatment was very
uncomfortable
Treatment was very
comfortable
B
This was the worst night sleep This was the best night sleep
in quite some time in quite some time
0 2 4 6 8 10
Figure 2. The morning following 1 night of treatment with
flow-targeted dynamic BPAP, the subjects completed a visual
analog scale. The analog scale included two items: (1) top, A: how
would you describe the comfort of the therapy you received
through the night? and (2) bottom, B: how would you describe
the quality of the rest you had last night? Possible values ranged
from 0 to 10. The mean rating SE after the first night with
flow-targeted dynamic BPAP for item 1 was 6.9 0.6 and for
item 2 was 7.4 0.6.
sleep efficiency. Again, none of these changes
reached statistical significance. As depicted in Figure
2, CHF patients perceived the first night of noctur-
nal treatment with flow-targeted dynamic BPAP as
comfortable and rated the quality of sleep as better
than average. Only one patient, who completed the
study but did not tolerate wearing a face mask, rated
below average in both analog scales.
Discussion
In the first clinical evaluation of the flow-targeted
dynamic BPAP device, patients with CHF and moder-
ate-to-severe CSR-CSA were evaluated. The major
findings are that CPAP/BPAP and flow-targeted dy-
namic BPAP reduced the frequency of apneas and
hypopneas during sleep. While the CHF patients had
substantial residual CSR-CSA with CPAP/BPAP ther-
apy, flow-targeted dynamic BPAP effectively elimi-
nated apneas and hypopneas during sleep on the first
night of treatment. These effects were accompanied by
a trend toward improved sleep continuity and sleep
architecture. Treatment with flow-targeted dynamic
BPAP was perceived as comfortable, and sleep quality
during the first night of device use was subjectively
improved compared to recent nights.
For this study, we selected CHF patients who had
residual CSR-CSA (AHI 10/h) during a previous
sleep study with conventional CPAP or BPAP. Com-
pared to the first night without treatment, we found
a significant reduction of AHI and central apnea
index of 52% and 53%, respectively, during the night
with CPAP or BPAP. These findings are similar to
those reported from the CANPAP trial14 involving
258 heart failure patients with CSR-CSA (AHI
www.chestjournal.org
that CPAP reduced the AHI from 40 to 19/h of
sleep, indicating that a large proportion of patients
still had substantial CSR-CSA (AHI 15/h of sleep)
when receiving CPAP. In the only trial that com-
pared the CPAP and BPAP (without back-up rate)
treatment after 1 night, Kohnlein et al17 found
that BPAP and CPAP led to similar improvements in
CSR-CSA in 16 CHF patients.
In our clinical evaluation of flow-targeted dynamic
BPAP in CHF patients with CSR-CSA, we observed
a near elimination of CSR-CSA (AHI from 46 to 4/h
of sleep) during the first night of treatment. The
comparison of the approximately 90% AHI reduc-
tion with flow-targeted dynamic BPAP to the approx-
imately 50% AHI reduction with CPAP or BPAP in
our clinical evaluation as well as in the CANPAP
trial14 strongly suggests that flow-targeted dynamic
BPAP is more effective than CPAP in normalizing
nocturnal breathing in CHF patients with CSR-CSA.
Our observed results with flow-targeted dynamic
BPAP on CSR-CSA were similar to those trials evalu-
ating a device with volume-targeted adaptive servoven-
tilation. Teschler and colleagues19 studied 14 CHF
patients with similar CSR-CSA severity and observed
an 86% reduction in AHI, with a residual AHI of 6/h of
sleep. In another study, Morgenthaler and collegues20
observed a near elimination of respiratory events (AHI of
1/h of sleep) in 21 patients with predominantly normal
cardiac function and CSR-CSA, mixed sleep apnea, or
complex sleep apnea, who had a residual AHI of 34/h of
sleep with conventional CPAP (not part of the trial).
Suppression of CSR-CSA and normalization of
nocturnal oxygenation by flow-targeted dynamic
BPAP were accompanied by trends toward improved
objective measures of sleep continuity and quality.
However, none of these effects reached statistical
significance, which may be a result of a lack of study
power rather than a lack of effect. The magnitude of
effects of flow-targeted dynamic BPAP on sleep
efficiency and slow-wave sleep compare to those of
Teschler and colleagues19 with volume-triggered
adaptive servoventilation.
This first clinical evaluation of flow-targeted dynamic
BPAP has to be interpreted considering the following
limitations: it is possible that a full night of fixed optimal
CPAP or BPAP would have suppressed CSR-CSA
more effectively as our CPAP/BPAP night that in-
cluded titration. However, we do not believe that this
influenced our results significantly because only pa-
tients with a residual AHI 10/h during a previous
sleep study with conventional CPAP or BPAP therapy
(not part of this trial) were included, and patients spent
80% receiving optimal CPAP/BPAP settings during
the titration night in our trial. Moreover, the observed
52% reduction of CSR-CSA events by CPAP/BPAP
CHEST / 134 / 1 / JULY, 2008 65
conforms with the CPAP effects on CSR-CSA demon-
strated in the CANPAP trial14 after long-term treat-
ment, indicating that full suppression of CSR-CSA by
CPAP is not possible in all patients.
BPAP with a timed back-up rate may have sup-
pressed CSA more effectively than conventional
CPAP19 or BPAP without a back-up rate. However,
this treatment modality has not been tested for 1
night of treatment in patients with CHF and CSA,19
and hence its effect on cardiovascular outcomes and
clinical significance in such patients is unknown.
Therefore, we tested the effects of flow-targeted
dynamic BPAP on CSA in CHF patients with resid-
ual CSA on conventional treatment modalities such
as CPAP or BPAP without a back-up rate who were
studied over longer periods of time.14,17 Our clinical
evaluation assessed the effects on CSR-CSA only
during the first night of flow-targeted dynamic
BPAP. Although it has been demonstrated in the
CANPAP trial14 that the alleviation of CSR-CSA by
positive airway pressure support are sustained over 2
years, it has to be confirmed in longer-term trials
whether the elimination of CSR-CSA by flow-targeted
dynamic BPAP is sustained over such time periods.
There was a possible order effect in our study
because the CPAP/BPAP study always preceded the
flow-targeted dynamic BPAP evaluation. However,
because subjects were exposed to the nightly use of
a positive airway pressure device already for 27
weeks before this clinical evaluation, an order effect
is unlikely to influence sleep quality and apnea/
hypopnea frequency. Thus, we do not believe this
influenced our results. Finally, our results cannot be
extrapolated to women because we studied only men.
In summary, flow-targeted dynamic BPAP effec-
tively suppresses apneas and hypopneas in CHF pa-
tients with residual CSR-CSA receiving conventional
CPAP/BPAP therapy. Flow-targeted dynamic BPAP
was perceived as a comfortable treatment and subjec-
tively improved sleep quality. In view of the current
literature10,12,13,15,16 that suggests that suppression of
CSR-CSA is a possible mechanism through which
forms of positive airway pressure exert beneficial car-
diovascular effects in patients with CHF and CSR-
CSA, the longer-term effects on hemodynamics, car-
diac function, and survival of dynamic BPAP support in
patients with CHF merit further investigation.
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Original Research