Current and Future Use of Adaptive Servo-Ventilation

European Respiratory & Pulmonary Diseases, 2016;2(1):18-22 DOI:


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:
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

1. Teschler H, Dohring J, Wang YM, Berthon-Jones M, Adaptive pressure support servo-ventilation: a novel treatment for Cheyne-Stokes respiration in heart failure, Am J Respir Crit Care Med, 2001;164:614–9.
2. Javaheri S, Brown LK, Randerath WJ, Clinical applications of adaptive servoventilation devices: part 2, Chest, 2014;146:858–68.
3. Javaheri S, Brown LK, Randerath WJ, Positive airway pressure therapy with adaptive servoventilation: part 1: operational algorithms, Chest, 2014;146:514–23.
4. Cowie MR, Woehrle H, Wegscheider K, et al., Adaptive servoventilation for central sleep apnea in systolic heart failure, N Engl J Med, 2015;373:1095–105.
5. Cowie MR, Woehrle H, Wegscheider K, et al., Rationale and design of the SERVE-HF study: treatment of sleep-disordered breathing with predominant central sleep apnoea with adaptive servo-ventilation in patients with chronic heart failure, Eur J Heart Fail, 2013;15:937–43.
6. Bhatia RS, Tu JV, Lee DS, et al., Outcome of heart failure with preserved ejection fraction in a population-based study, N Engl J Med, 2006;355:260–9.
7. Borlaug BA, Redfield MM, Diastolic and systolic heart failure are distinct phenotypes within the heart failure spectrum, Circulation, 2011;123:2006–13; discussion 2014.
8. McMurray JJ, Adamopoulos S, Anker SD, et al.; Guidelines ESCCfP. ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 2012: The Task Force for the Diagnosis and Treatment of Acute and Chronic Heart Failure 2012 of the European Society of Cardiology. Developed in collaboration with the Heart Failure Association (HFA) of the ESC, Eur Heart J, 2012;33:1787–847.
9. Bitter T, Westerheide N, Faber L, et al., Adaptive servoventilation in diastolic heart failure and Cheyne-Stokes respiration, Eur Respir J, 2010;36:385–92.
10. Yoshihisa A, Suzuki S, Yamaki T, et al., Impact of adaptive servo-ventilation on cardiovascular function and prognosis in heart failure patients with preserved left ventricular ejection fraction and sleep-disordered breathing, Eur J Heart Fail, 2013;15:543–50.
11. International Classification of Sleep Disorders, 3rd ed. American Academy of Sleep Medicine, Darien, IL, USA. 2014.
12. Cassel W, Canisius S, Becker HF, et al., A prospective polysomnographic study on the evolution of complex sleep apnoea, Eur Respir J, 2011;38:329–37.
13. Dernaika T, Tawk M, Nazir S, et al., The significance and outcome of continuous positive airway pressure-related central sleep apnea during split-night sleep studies, Chest, 2007;132:81–7.
14. Javaheri S, Smith J, Chung E, The prevalence and natural history of complex sleep apnea, J Clin Sleep Med, 2009;5:205–11.
15. Morgenthaler TI, Kuzniar TJ, Wolfe LF, et al., The complex sleep apnea resolution study: a prospective randomized controlled trial of continuous positive airway pressure versus adaptive servoventilation therapy, Sleep, 2014;37:927–34.
16. Morgenthaler TI, Gay PC, Gordon N, Brown LK, Adaptive servoventilation versus noninvasive positive pressure ventilation for central, mixed, and complex sleep apnea syndromes, Sleep, 2007;30:468–75.
17. Javaheri S, Winslow D, McCullough P, et al., The use of a fully automated automatic adaptive servo ventilation algorithm in the acute and chronic treatment of central sleep apnea, Chest, 2015;148:1454–61.
18. Allam JS, Olson EJ, Gay PC, Morgenthaler TI, Efficacy of adaptive servoventilation in treatment of complex and central sleep apnea syndromes, Chest, 2007;132:1839–46.
19. Brown SE, Mosko SS, Davis JA, et al., A retrospective case series of adaptive servoventilation for complex sleep apnea, J Clin Sleep Med, 2011;7:187–95.
20. Ramar K, Desrues B, Ramar P, Morgenthaler TI, Analysis of cardiopulmonary coupling to assess adaptive servoventilation success in complex sleep apnea management, Sleep Breath, 2013;17:861–6.
21. Rose AR, Catcheside PG, McEvoy RD, et al., Sleep disordered breathing and chronic respiratory failure in patients with chronic pain on long term opioid therapy, J Clin Sleep Med, 2014;10:847–52.
22. Webster LR, Choi Y, Desai H, et al., Sleep-disordered breathing and chronic opioid therapy, Pain Med, 2008;9:425–32.
23. Reddy R, Adamo D, Kufel T, et al., Treatment of opioidrelated central sleep apnea with positive airway pressure: a systematic review, J Opioid Manag, 2014;10:57–62.
24. Shapiro CM, Chung SA, Wylie PE, et al., Home-use servoventilation therapy in chronic pain patients with central sleep apnea: initial and 3-month follow-up, Sleep Breath, 2015;19:1285–92.
25. Javaheri S, Harris N, Howard J, Chung E, Adaptive servoventilation for treatment of opioid-associated central sleep apnea, J Clin Sleep Med, 2014;10:637–43.
26. Ramar K, Ramar P, Morgenthaler TI, Adaptive servoventilation in patients with central or complex sleep apnea related to chronic opioid use and congestive heart failure, J Clin Sleep Med, 2012;8:569–76.
27. Farney RJ, Walker JM, Boyle KM, et al., Adaptive servoventilation (ASV) in patients with sleep disordered breathing associated with chronic opioid medications for non-malignant pain, J Clin Sleep Med, 2008;4:311–9.
28. Javaheri S, Malik A, Smith J, Chung E, Adaptive pressure support servoventilation: a novel treatment for sleep apnea associated with use of opioids, J Clin Sleep Med, 2008;4:305–10.
29. Cao M, Cardell CY, Willes L, et al., A novel adaptive servoventilation (ASVAuto) for the treatment of central sleep apnea associated with chronic use of opioids, J Clin Sleep Med, 2014;10:855–61.
30. Banno K, Okamura K, Kryger MH, Adaptive servo-ventilation in patients with idiopathic Cheyne-Stokes breathing, J Clin Sleep Med, 2006;2:181–6.
31. Bassetti CL, Milanova M, Gugger M, Sleep-disordered breathing and acute ischemic stroke: diagnosis, risk factors, treatment, evolution, and long-term clinical outcome, Stroke, 2006;37:967–72.
32. Parra O, Arboix A, Bechich S, et al., Time course of sleeprelated breathing disorders in first-ever stroke or transient ischemic attack, Am J Respir Crit Care Med, 2000;161(2 Pt 1):375–80.
33. Harbison J, Ford GA, James OF, Gibson GJ, Sleep-disordered breathing following acute stroke, QJM, 2002;95:741–7.
34. Brill AK, Rosti R, Hefti JP, et al., Adaptive servo-ventilation as treatment of persistent central sleep apnea in post-acute ischemic stroke patients, Sleep Med, 2014;15:1309–13.
35. Tamisier R, Damy T, Davy J-M, et al., Adaptive servoventilation (ASV) decreases unplanned hospitalisations in chronic heart failure (CHF) patients with central sleep apnoea (CSA): the French multicentre, prospective FACE cohort study, European Respiratory Society Congress 2015 [abstract].
Keywords: Adaptive servo-ventilation, central sleep apnoea, treatment-emergent sleep apnoea, opioids, stroke, heart failure