Republic of the Philippines

NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY

Cabanatuan City, Nueva Ecija, Philippines

COLLEGE OF NURSING

THE USE OF
ADAPTIVE SERVO
VENTILATION
THERAPY FOR
CENTRAL SLEEP
APNEA
Submitted By:
Plamenco, John Carlo
Sabado, Lia Maxine
Sarmiento, Mae Claire
Villaseñ or, Dariane Joy

Submitted to:
Sir June Reguyal MAN, RN

Telefax No. (044) 463-0226

Transforming Communities through Science and Technology neustmain@yahoo.com
www.neust.edu.ph
 Republic of the Philippines
NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY
Cabanatuan City, Nueva Ecija, Philippines

COLLEGE OF NURSING

Introduction
Adaptive Servo-Ventilation Machine (ASV)

ASV machines consist of three basic parts:

- a face mask, the machine, and a flexible hose that connects the mask to the machine.
Before falling asleep, the person puts on the mask and turns on the machine. ASV masks may
either be fitted over the nose and the mouth, or just the nose. The goal of ASV is to minimize
auto-PEEP and work of breathing for the patient.

It's a mode of ventilation that changes the number of mandatory breaths and pressure support
level according to the patient's breathing pattern. This means that it's a dual-control mode that
provides a mandatory minute ventilation.

TASV provides pressure-limited breaths that target a tidal volume and rate that is selected by
the ventilator's algorithm to provide minimal work of breathing for the patient.
It monitors variables such as pressure, flow, inspiratory and expiratory time, compliance,
resistance, and time constants to ensure delivery of an acceptable minute ventilation based on
the settings that are entered by the practitioner.

The goal of ASV is to minimize auto-PEEP and work of breathing for the patient.

PROBLEM/POPULATION
Who Is ASV Best For?
ASV was originally developed for people with Cheyne-Stokes respirations, a condition linked to heart failure that
involves hyperventilation followed by lapses in breathing. ASV therapy is used to treat sleep- disordered breathing
in people with:

 Central sleep apnea (CSA), including CSA due to stroke, kidney failure, neurological conditions, or opioid
use
 Complex sleep apnea, or treatment-emergent central sleep apnea, which arises during OSA treatment
 Mixed sleep apnea, involving obstructive and central apneic events

INTERVENTION/INDICATION
Adaptive Servo-Ventilation (ASV) is primarily used for people with central sleep apnea. A non-invasive ventilatory
treatment and positive airway pressure (PAP) unit, ASV works by continuously monitoring for abnormalities and
adjusting to correct individuals’ breathing impacts.

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 Republic of the Philippines
NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY
Cabanatuan City, Nueva Ecija, Philippines

COLLEGE OF NURSING

How do ASV machines work?

Adaptive servo ventilation involves the motor-powered compressor within the base unit of the ASV machine
providing a stream of pressurised air that travels through an air filter and is delivered to the patient’s mask via the
air tube.

This eliminates potential obstructions from the patient’s airways, as the stream of air from the machine pushes
against any blockages and opens the patient’s airways so that their lungs can receive plenty of oxygen.

It can also detect abnormalities in breathing, and it intervenes with just enough support to keep the patient’s
breathing at 90% of what it had been before the abrupt change in breathing. The machine re-adjusts itself to the
patient’s normal breathing pattern after the patient’s breathing returns to normal. By providing just enough
pressure support, ASV reduces the work of breathing by approximately 50% for the patient.

Like CPAP devices, ASV machines consist of three basic parts: a face mask, the machine, and a flexible hose that
connects the mask to the machine. Before falling asleep, the person puts on the mask and turns on the machine.
ASV masks may either be fitted over the nose and the mouth, or just the nose .

COMPARISON

Adaptive Servo Ventilation is one of multiple types of PAP machines. Each of these devices deliver oxygen to
sleeping patients, however there are differences in their methods. Adaptive Servo Ventilation stands out from the
others because it is the only one to autonomously adapt to the patient’s breathing. Because of this, ASV is brought
in as a last resort for patients who are unable to have their sleep apnoea symptoms be adequately treated by CPAP
or BiPAP devices.

HOW IS ASV DIFFERENT FROM A CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) MACHINE?
While ASV and CPAP machines are both categorized as positive airway pressure units, they have a handful of
differences. CPAP works by continuously delivering a pre-set or fixed amount of air pressure to the user. On the
other hand, ASV responds to the user’s breathing and adjusts the amount of air pressure it administers.

ASV vs. CPAP: What’s the Difference?

As opposed to ASV machines, both CPAP and regular BiPAP devices deliver air pressure in a pre-set way:
 Continuous positive airway pressure (CPAP) machines deliver a set amount of air pressure continuously
throughout the night.
 Bi-level positive airway pressure (BiPAP) machines can be adjusted to provide a different level of pressure
when the person exhales.

Unlike CPAP and BiPAP machines, ASV devices adapt to the individual throughout the night, using algorithms to
adjust the air pressure as necessary to fit their breathing patterns.

OUTCOME

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 Republic of the Philippines
NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY
Cabanatuan City, Nueva Ecija, Philippines

COLLEGE OF NURSING

The ASV device monitors a person’s breathing throughout the night. If a person’s breathing slows down, the
machine responds with enough pressure to return them to normal breathing levels. Once their breathing goes back
to normal, the ASV machine lowers the pressure, but may still provide a baseline level of support to make it easier
for the person to breathe normally. This method helps regularize breathing for people who respond poorly to CPAP
therapy , and the variability in air pressure may also relieve some of the discomfort people feel with CPAP therapy .

In the study entitled The use and effectiveness of adaptive servo ventilation in central sleep apnea: a study
of consecutive sleep clinic patient.

Results show that adaptive servo ventilation was effective and superior to continuous positive airway pressure in
controlling central sleep apnea and improving symptoms. Only a small proportion of these patients had comorbid
heart failure. Early treatment with adaptive servo ventilation may improve long-term adherence to therapy

ASV Pros and Cons

The advantages of ASVs include:

 Comfort. Some people find them more comfortable to use than a CPAP. ASVs change air pressure levels on
an ongoing basis to adapt to your breathing patterns through the night.
 Easier to use. Since ASV works better for some types of sleep apnea, you may be more likely to stick with it.
 Better for certain types:
 Central sleep apnea. If you have central sleep apnea, an ASV can tell when your breathing pattern changes
while you sleep. It gives you air when you need it, so you breathe more easily. It also makes sure you get
enough oxygen during the night.
 Complex sleep apnea. ASVs are more effective than CPAP for relief of complex sleep apnea. They can
restore normal, stable breathing and improve your ability to have sound sleep.

ASVs may have some downsides, too. Don’t use them if you have one of these conditions:

 Chronic heart failure and central sleep apnea, as it may be life-threatening

 Moderate to severe chronic obstructive pulmonary disease (COPD)
 Chronic hypoventilation (shallow breathing)

RESEARCH STUDIES

The use and effectiveness of adaptive servo ventilation in central sleep apnea: a study of consecutive sleep
clinic patient

Results show that adaptive servo ventilation was effective and superior to continuous positive airway pressure in
controlling central sleep apnea and improving symptoms. Only a small proportion of these patients had comorbid
heart failure. Early treatment with adaptive servo ventilation may improve long-term adherence to therapy

https://onlinelibrary.wiley.com/doi/10.1111/jsr.13016#:~:text=Results%20show%20that%20adaptive
%20servo,sleep%20apnea%20and%20improving%20symptoms.

Adaptive servo-ventilation in heart failure patients with sleep apnea: A real world study
Background
Congestive heart failure (CHF) patients often present with obstructive and central sleep apnea occurring
concurrently within the same night. This study assessed the efficacy of, and improvements associated with, the use
of adaptive servo-ventilation (ASV) in CHF patients with all types of sleep apnea. We hypothesized that ASV would
be effective at reducing sleep apnea and improving both cardiac status and quality of life.

Methods
Eleven male patients with stable CHF and sleep apnea (apnea/hypopnea index (AHI) > 15 events/h) were treated
with 6 months optimized ASV and compared to 8 patients not receiving ASV. At baseline, both groups were
comparable for New York Heart Association class, left ventricular ejection fraction (LVEF), plasma Brain
Natriuretric Peptide (BNP) concentrations and AHI. All patients were receiving optimal medical therapy.

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 Republic of the Philippines
NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY
Cabanatuan City, Nueva Ecija, Philippines

COLLEGE OF NURSING
Results
At 6 months ASV significantly reduced AHI (mean (SD), baseline 49.0 (35.1) v ASV 7.6 (14.6); p = 0.001) and LVEF
was increased (median (inter-quartile range), treatment group: + 5.7 (1.6–9.5) v comparison group: − 4.0 (− 8.9–
+ 4.6)% respectively; p = 0.04) but not BNP (p = 0.59). The energy/vitality score of the SF-36 quality of life
questionnaire was also improved at 6 months (treatment group: + 10 (5–35) v comparison group: − 12 (− 18–
+ 10); p = 0.005).

Conclusion
ASV effectively reduces all types of sleep apnea. Six months of use is associated with improvement in LVEF and
aspects of quality of life.
https://pubmed.ncbi.nlm.nih.gov/18805598/

Effect of Flow-Triggered Adaptive Servo-Ventilation Compared With Continuous Positive Airway Pressure in
Patients With Chronic Heart Failure With Coexisting Obstructive Sleep Apnea and Cheyne-Stokes
Respiration

Background— In patients with chronic heart failure (CHF), the presence of sleep-disordered breathing, including
either obstructive sleep apnea or Cheyne-Stokes respiration-central sleep apnea, is associated with a poor
prognosis. A large-scale clinical trial showed that continuous positive airway pressure (CPAP) did not improve the
prognosis of such patients with CHF, probably because of insufficient sleep-disordered breathing suppression.
Recently, it was reported that adaptive servo-ventilation (ASV) can effectively treat sleep-disordered breathing.
However, there are no specific data about the efficacy of flow-triggered ASV for cardiac function in patients with
CHF with sleep-disordered breathing. The aim of this study was to compare the efficacy of flow-triggered ASV to
CPAP in patients with CHF with coexisting obstructive sleep apnea and Cheyne-Stokes respiration-central sleep
apnea.

Methods and Results— Thirty-one patients with CHF, defined as left ventricular ejection fraction <50% and New
York Heart Association class ≥II, with coexisting obstructive sleep apnea and Cheyne-Stokes respiration-central
sleep apnea, were randomly assigned to either CPAP or flow-triggered ASV. The suppression of respiratory events,
changes in cardiac function, and compliance with the devices during the 3-month study period were compared.
Although both devices decreased respiratory events, ASV more effectively suppressed respiratory events (ΔAHI
[apnea-hypopnea index], −35.4±19.5 with ASV; −23.2±12.0 with CPAP, P<0.05). Compliance was significantly
greater with ASV than with CPAP (5.2±0.9 versus 4.4±1.1 h/night, P<0.05). The improvements in quality-of-life
and left ventricular ejection fraction were greater in the ASV group (ΔLVEF [left ventricular ejection fraction],
+9.1±4.7% versus +1.9±10.9%).

Conclusions— These results suggest that patients with coexisting obstructive sleep apnea and Cheyne-Stokes
respiration-central sleep apnea may receive greater benefit from treatment with ASV than with CPAP.

https://www.ahajournals.org/doi/full/10.1161/CIRCHEARTFAILURE.109.868786

Efficacy of Adaptive Servoventilation in Treatment of Complex and Central Sleep Apnea Syndromes

Background
Complex sleep apnea syndrome (CompSAS) is recognized by the concurrence of mixed or obstructive events with
central apneas, the latter predominating on exposure to continuous positive airway pressure (CPAP). Treatment of
CompSAS or central sleep apnea (CSA) syndrome with adaptive servoventilation (ASV) is now an option, but no
large series exist describing the application and effectiveness of ASV.

Methods
Retrospective chart review of the first 100 patients who underwent polysomnography using ASV at Mayo Clinic
Sleep Center.

Results
ASV titration was performed for CompSAS (63%), CSA (22%), or CSA/Cheyne Stokes breathing patterns (15%).
The median diagnostic sleep apnea hypopnea index (AHI) was 48 events per hour (range, 24 to 62). With CPAP,
obstructive apneas decreased, but the appearance of central apneas maintained the AHI at 31 events per hour
(range, 17 to 47) [p = 0.02]. With bilevel positive airway pressure (BPAP) in spontaneous mode, AHI trended

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 Republic of the Philippines
NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY
Cabanatuan City, Nueva Ecija, Philippines

COLLEGE OF NURSING
toward worsening vs baseline, with a median of 75 events per hour (range, 46 to 111) [p = 0.055]. BPAP with a
backup rate improved the AHI to 15 events per hour (range, 11 to 31) [p = 0.002]. Use of ASV dramatically
improved the AHI to a mean of 5 events per hour (range, 1 to 11) vs baseline and vs CPAP (p < 0.0001). ASV also
resulted in an increase in rapid eye movement sleep vs baseline and CPAP (18% vs 12% and 10%, respectively; p <
0.0001). Overall, 64 patients responded to the ASV treatment with a mean AHI < 10 events per hour. Of the 44
successful survey follow-up patients contacted, 32 patients reported some improvement in sleep quality.

Conclusion
The ASV device appears to be an effective treatment of both CompSAS and CSA syndromes that are resistant to
CPAP.
https://www.sciencedirect.com/science/article/abs/pii/S0012369215524550
Terminated
Adaptive Servo-Ventilation in Cardiac Function and Neurohormonal Status in Patients With Heart Failure
and Central Sleep Apnea Nonresponsive to Continuous Positive Airway Pressure

Objectives:
The aim of this study was to investigate whether effective suppression of central sleep apnea (CSA) by adaptive
servo-ventilation (ASV) improves underlying cardiac dysfunction among patients with heart failure (HF) in whom
CSA was not effectively suppressed by continuous positive airway pressure (CPAP).

Background:
The presence of CSA in HF is associated with a poor prognosis, whereas CPAP treatment improves HF. However, in
a large-scale trial, CPAP failed to improve survival, probably due to insufficient CSA suppression. Recently, ASV
was reported as the most effective alternative to CSA suppression. However, the effects of sufficient CSA
suppression by ASV on cardiac function are unknown.

Methods:
Patients with New York Heart Association class ≥II HF, left ventricular ejection fraction &lt;50%, and CSA that
was unsuppressed (defined as an apnea-hypopnea index ≥15) despite ≥3 months of CPAP were randomly assigned
to receive ASV in either CPAP mode or ASV mode.

Results:
Of 23 patients enrolled, 12 were assigned to the ASV-mode group and 11 were assigned to the CPAP-mode group.
Three months after randomization, the ASV mode was significantly more effective in suppressing the apnea-
hypopnea index (from 25.0 ± 6.9 events/h to 2.0 ± 1.4 events/h; p &lt; 0.001) compared to the CPAP mode.
Compliance was signi-ficantly greater with the ASV mode than with the CPAP mode. Improvement in left
ventricular ejection fraction was greater with the ASV mode (32.0 ± 7.9% to 37.8 ± 9.1%; p &lt; 0.001) than with
the CPAP mode.

Conclusions:
Patients with HF and unsuppressed CSA despite receiving CPAP may receive additional benefit by having CPAP
replaced with ASV. Additionally, effective suppression of CSA may improve cardiac function in HF patients.
https://www.jacc.org/doi/abs/10.1016/j.jchf.2012.11.002

REFERENCES:
https://houstonsleepsolutions.com/blog/sleep-apnea-treatments-what-is-adaptive-servo-ventilation-asv

https://www.sleepfoundation.org/sleep-apnea/asv-machines#:~:text=Unlike%20CPAP%20and%20BiPAP
%20machines,breathing%20during%20central%20apneic%20events

https://www.webmd.com/sleep-disorders/sleep-apnea/what-is-asv#1

https://houstonsleepsolutions.com/blog/sleep-apnea-treatments-what-is-adaptive-servo-ventilation-asv

https://www.sleepfoundation.org/sleep-apnea/asv-machines#:~:text=Unlike%20CPAP%20and%20BiPAP
%20machines,breathing%20during%20central%20apneic%20events

https://www.webmd.com/sleep-disorders/sleep-apnea/what-is-asv#1

Telefax No. (044) 463-0226

Transforming Communities through Science and Technology neustmain@yahoo.com
www.neust.edu.ph
 Republic of the Philippines
NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY
Cabanatuan City, Nueva Ecija, Philippines

COLLEGE OF NURSING
https://onlinelibrary.wiley.com/doi/10.1111/jsr.13016#:~:text=Results%20show%20that%20adaptive
%20servo,sleep%20apnea%20and%20improving%20symptoms

https://www.ahajournals.org/doi/full/10.1161/CIRCHEARTFAILURE.109.868786

https://www.sciencedirect.com/science/article/abs/pii/S0012369215524550

https://www.jacc.org/doi/abs/10.1016/j.jchf.2012.11.002

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www.neust.edu.ph