What are the indications for Bi-level Positive Airway Pressure (BiPAP) therapy in patients with Chronic Obstructive Pulmonary Disease (COPD)?

From the Guidelines

BiPAP (Bilevel Positive Airway Pressure) is indicated for COPD patients experiencing acute exacerbations with respiratory acidosis (pH < 7.35) and hypercapnia (PaCO2 > 45 mmHg), despite maximal medical therapy, as stated in the official ERS/ATS clinical practice guidelines 1.

Indications for BiPAP Therapy

The following are specific indications for BiPAP therapy in COPD patients:

• Moderate to severe dyspnea with signs of increased work of breathing
• Respiratory rate > 25 breaths per minute
• PaCO2 > 45 mmHg with pH < 7.35

Initial BiPAP Settings

Initial BiPAP settings should be:

• IPAP (Inspiratory Positive Airway Pressure): Start at 10-12 cmH2O, increase as needed
• EPAP (Expiratory Positive Airway Pressure): Start at 4-5 cmH2O
• Adjust settings to achieve tidal volumes of 6-8 mL/kg ideal body weight

Monitoring and Adjustment

Monitor the patient closely for the first 1-2 hours, and if there's no improvement in respiratory rate, work of breathing, or blood gases within this time, consider intubation and mechanical ventilation, as recommended by the American Thoracic Society clinical practice guideline 1.

Mechanism of Action

BiPAP works by providing positive pressure support during inspiration, which reduces the work of breathing, and maintaining positive pressure during expiration, which helps prevent alveolar collapse, thereby improving gas exchange, reducing respiratory muscle fatigue, and helping correct respiratory acidosis in COPD patients experiencing acute exacerbations, as supported by the European Respiratory Journal study 1.

Long-term Use

For stable patients with COPD and chronic hypercapnia, long-term NIV has the potential to improve physiological parameters, clinical symptoms, and patient-centered outcomes, such as hospital readmission and survival, as stated in the American Journal of Respiratory and Critical Care Medicine study 1. However, the use of BiPAP in this setting should be individualized and based on the patient's specific needs and response to therapy.

From the Research

Indications for Bi-level Positive Airway Pressure (BiPAP) Therapy in COPD Patients

• BiPAP therapy is indicated for patients with acute respiratory failure due to acute exacerbation of Chronic Obstructive Pulmonary Disease (COPD) 2, 3, 4
• BiPAP is particularly useful in patients presenting with acute respiratory failure due to acute exacerbation of COPD, especially in settings where invasive ventilation is not easily available 2
• Non-invasive ventilation (NIV) with BiPAP is effective in treating patients with acute hypercapnic respiratory failure secondary to an acute exacerbation of COPD 4
• BiPAP can be used to reduce the likelihood of mortality and endotracheal intubation in patients admitted with acute hypercapnic respiratory failure secondary to an acute exacerbation of COPD 4

Benefits of BiPAP Therapy in COPD Patients

• Decreased risk of mortality by 46% 4
• Decreased risk of needing endotracheal intubation by 65% 4
• Reduced length of hospital stay 4
• Reduced incidence of complications unrelated to NIV 4
• Improvement in pH and partial pressure of oxygen (PaO2) at one hour 4

Patient Selection for BiPAP Therapy

• Patients with acute exacerbation of COPD and hypercapnic respiratory failure 2, 3, 4
• Patients with severe pulmonary hypertension may have a poorer response to NIV treatment 3
• Patients with type II respiratory failure due to acute exacerbation of COPD may benefit from BiPAP therapy 5