Strengthening the Cardiopulmonary Dialogue: Why Respiratory Therapists Belong at the Heart Failure Table

To the Editor, Acute cardiogenic pulmonary edema exemplifies the close physiological relationship between cardiac and respiratory function, yet clinical management often remains fragmented across cardiology and respiratory care services. Non-invasive ventilation (NIV), including continuous positive airway pressure (CPAP) and bilevel positive airway pressure, is an important therapeutic intervention that improves oxygenation, reduces respiratory effort, and favorably influences cardiac loading conditions through changes in intrathoracic pressure. Evidence from systematic reviews and meta-analyses demonstrates that NIV reduces the need for endotracheal intubation and may improve clinical outcomes in appropriately selected patients with acute cardiogenic pulmonary edema [1,2]. However, the magnitude of mortality benefit varies across studies, emphasizing the importance of appropriate patient selection, timely initiation, and coordinated clinical management. Despite these established benefits, respiratory support may be delayed when NIV initiation depends on sequential consultation rather than integrated clinical protocols. Such delays highlight the need for closer collaboration between cardiologists, emergency physicians, and respiratory therapists. Respiratory therapists contribute specialized expertise in ventilatory assessment, interface selection, pressure titration, patient tolerance, and ongoing monitoring, all of which are essential for optimizing respiratory support while minimizing adverse hemodynamic consequences. Another important consideration is patient–ventilator asynchrony (PVA), particularly among patients with compromised cardiac function. Ineffective triggering, delayed cycling, and other forms of asynchrony may increase respiratory effort, impair ventilatory efficiency, and contribute to patient discomfort. Furthermore, changes in intrathoracic pressure during positive-pressure ventilation can influence venous return, ventricular loading conditions, and cardiac output. These interactions underscore the importance of considering cardiopulmonary physiology when adjusting ventilatory settings rather than focusing exclusively on gas exchange [3]. Integrating ventilator waveform interpretation and hemodynamic assessment into interdisciplinary training may improve the recognition and management of clinically significant asynchrony. The relationship between obstructive sleep apnea (OSA) and cardiovascular disease further illustrates the importance of sustained cardiopulmonary collaboration. OSA is common among patients with heart failure and is associated with intermittent hypoxemia, sympathetic activation, and adverse cardiovascular outcomes, including atrial arrhythmias [4]. CPAP therapy is an established treatment for appropriately diagnosed OSA, while observational evidence suggests that treatment adherence may be associated with improved rhythm-related outcomes in selected patients with atrial fibrillation undergoing catheter ablation [5]. Nevertheless, the cardiovascular benefits of CPAP should be interpreted cautiously because observational associations do not necessarily establish causality. Effective long-term management requires coordinated screening, treatment selection, adherence support, and cardiovascular follow-up. These clinical examples reinforce the need to move beyond discipline-specific approaches toward integrated cardiopulmonary care. Healthcare institutions should consider developing collaborative protocols for early NIV assessment and initiation, shared monitoring of ventilatory and hemodynamic responses, and structured follow-up for patients with sleep-disordered breathing and cardiovascular disease. Furthermore, interdisciplinary educational programs involving cardiologists, respiratory therapists, and critical care professionals could strengthen clinical decision-making and improve continuity of care. Ultimately, respiratory therapists should be recognized not merely as technical providers of ventilatory support but as integral members of the multidisciplinary cardiovascular care team. Strengthening collaboration between respiratory therapy and cardiology offers an opportunity to improve the coordination, safety, and physiological precision of care for patients with complex cardiopulmonary conditions. References Vital FM, Ladeira MT, Atallah AN. Non-invasive positive pressure ventilation (CPAP or bilevel NPPV) for cardiogenic pulmonary oedema. Cochrane Database Syst Rev. 2013;(5):CD005351. DOI: 10.1002/14651858.CD005351.pub3 Masip J, Roque M, Sánchez B, Fernández R, Subirana M, Expósito JA. Noninvasive ventilation in acute cardiogenic pulmonary edema: systematic review and meta-analysis. JAMA. 2005;294(24):3124-30. DOI: 10.1001/jama.294.24.3124 de Haro C, Ochagavia A, López-Aguilar J, Fernandez-Gonzalo S, Navarra-Ventura G, Magrans R, et al. Patient-ventilator asynchronies during mechanical ventilation: current knowledge and research priorities. Intensive Care Med Exp. 2019;7(Suppl 1):43. DOI: 10.1186/s40635-019-0234-5 Bandi PS, Panigrahy PK, Hajeebu S, Ngembus NJ, Heindl SE. Pathophysiological mechanisms to review association of atrial fibrillation in heart failure with obstructive sleep apnea. Cureus. 2021;13(7):e16086. DOI: 10.7759/cureus.16086 Tanaka N, Okada M, Tanaka K, Hirao Y, Miyazaki N, Iwasa K, et al. Impact of long-term CPAP adherence on recurrence after atrial fibrillation ablation in patients with severe sleep apnea. J Am Heart Assoc. 2025;14(10):e038742. DOI: 10.1161/JAHA.124.038742