Management of Mechanical Ventilation in Decompensated Heart Failure

The hemodynamic benefits of MV are often-overlooked in patients with decompensated

congestive heart failure and cardiogenic shock in particular. Favorable effects of MV in acute decompensated HF include reducing ventricular preload and afterload, decreasing extra-vascular lung water, and decreasing the work of breathing and its associated cardiac output requirements. The appropriate use of MV should be seen as an important adjunctive therapy in the initial stabilization and management of patients with decompensated HF and acute respiratory failure. Patients with acute decompensated HF require special attention to ventilator weaning and liberation from MV since HF is well recognized as a risk factor for extubation failure and the need for re-intubation. Spontaneous breathing trials without ventilator support (i.e., T-piece trials) may reveal the need for further medical optimization of preload, afterload, and contractility prior to planned extubation since removal of even a seemingly trivial amount of support can result in hemodynamic instability, flash pulmonary edema,

and rapid decompensation. Prophylactic use of non-invasive positive pressure ventilation immediately upon extubation may prevent re-intubation in patients with marginal cardiac function but non-invasive ventilation should not be thought of as a rescue therapy for patients who develop acute respiratory failure after extubation since this practice has been associated with increased mortality compared to medical therapy alone with prompt re-intubation if needed. When carefully applied, both invasive mechanical ventilation and non-invasive positive pressure ventilation should be considered important tools in the successful management of respiratory failure in patients with acute decompensated HF.

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