Current and Future Use of Adaptive Servo-Ventilation

European Respiratory & Pulmonary Diseases, 2016;2(1):18-22 DOI: http://doi.org/10.17925/ERPD.2016.02.01.1

Abstract:

Adaptive servo-ventilation (ASV) is a form of non-invasive positive airway pressure (PAP) therapy that differs from other PAP devices. It includes features to overcome both obstructive and central sleep-disordered breathing (SDB) events. In the Treatment of Sleep-Disordered Breathing with Predominant Central Sleep Apnea by Adaptive Servo-Ventilation in Patients with Heart Failure (SERVE-HF) study, ASV significantly reduced SDB events in patients with systolic heart failure (HF) and predominant central sleep apnoea (CSA), but did not improve outcomes, and there was increased mortality risk in the ASV group. Although the SERVE-HF results represent a paradigm shift for ASV, they are only applicable to a small subset of ASV-treated patients, and there is no evidence suggesting that ASV use should stop altogether. There are a number of other indications and patient groups for whom ASV may be useful, effective and safe, including patients with treatment-emergent CSA, central apnoeas associated with long-term opioid therapy without alveolar hypoventilation, idiopathic Cheyne-Stokes respiration, after ischaemic stroke and those with HF with preserved ejection fraction. Additional research is required to better define the mechanism of increased risk associated with ASV identified in SERVE-HF and to more clearly characterise the specific patient phenotypes who benefit from ASV therapy.
Keywords: Adaptive servo-ventilation, central sleep apnoea, treatment-emergent sleep apnoea, opioids, stroke, heart failure
Disclosure: Marie-Pia d’Ortho has received grants from Fisher & Paykel Healthcare and ADEP Assistance, grants and personal fees from ResMed, Philips Respironics and IP Sante and personal fees and non-financial support from Vitalaire. Holger Woehrle is an employee of ResMed Germany. Michael Arzt has received unrestricted grant support from Philips Home Healthcare Solutions, ResMed Germany and the German Foundation for Cardiac Research (Deutsche Stiftung für Herzforschung); he is also the holder of an endowed professorship from the Free State of Bavaria at the University of Regensburg that was donated by Philips Home Healthcare Solutions and ResMed Germany.
Acknowledgments: Medical writing assistance was provided by Nicola Ryan, independent medical writer, funded by RedMed.
Received: November 22, 2015 Accepted December 11, 2015
Correspondence: Marie-Pia d’Ortho, Service de Physiologie Explorations Fonctionnelles, Hôpital Bichat - University Paris Diderot, Sorbonne Paris Cité, DHU FIRE, AP-HP, 48 rue Henri Huchard, 75018 Paris, France. E: marie-pia.dortho@bch.aphp.fr
Support: The publication of this article was supported by ResMed. The views and opinions expressed are those of the author and do not necessarily reflect those of ResMed.
Open Access: This article is published under the Creative Commons Attribution Noncommercial License, which permits any non-commercial use, distribution, adaptation and reproduction provided the original author(s) and source are given appropriate credit.

Adaptive servo-ventilation (ASV) is a non-invasive ventilatory therapy that provides variable inspiratory positive airway pressure (IPAP) to support inspiration when breathing amplitude is reduced, ensures sufficient respiration when respiratory effort is absent and provides fixed or variable end-expiratory PAP (EPAP) to maintain upper airway patency. This approach is designed to mimic nasal continuous PAP (CPAP) in terms of pneumatically opening the upper airway and to directly suppress central sleep apnoeas without causing overventilation.1 In hypocapnic central sleep apnoea (CSA), where hyperventilation plays a major role, ASV has been shown to slightly increase carbon dioxide levels in patients with heart failure (HF).1

The pressure profile provided by ASV devices differs from those of other PAP therapies (see Figure 1). Although default settings are available, sleep laboratory-based individualised titration for each patient is more appropriate,2 and the best approach to maintain patient comfort, maximise adherence and preserve haemodynamics is to use minimum effective settings for IPAP, EPAP and back-up rate.3

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Keywords: Adaptive servo-ventilation, central sleep apnoea, treatment-emergent sleep apnoea, opioids, stroke, heart failure