What is the role of BiPAP (Bilevel Positive Airway Pressure) in managing patients with pleural effusion?

From the Guidelines

BiPAP is generally not recommended as a primary treatment for pleural effusion but may be used as a supportive measure in specific situations. The management of pleural effusion primarily involves addressing the underlying cause and drainage of the fluid when clinically indicated, rather than respiratory support alone 1. BiPAP works by delivering two levels of positive airway pressure - higher pressure during inhalation and lower pressure during exhalation - which can help patients with respiratory distress associated with large pleural effusions. It may be used temporarily to improve oxygenation and reduce work of breathing while preparing for definitive treatments such as thoracentesis, chest tube placement, or treating the underlying cause of the effusion.

Some key points to consider in the management of pleural effusion include:

• The use of ultrasound imaging to guide pleural interventions, as suggested by the American Thoracic Society 1.
• The consideration of large-volume thoracentesis to assess lung expansion in patients with symptomatic MPE, if it is uncertain whether the patient’s symptoms are related to the effusion and/or if the lung is expandable 1.
• The use of either an indwelling pleural catheter (IPC) or chemical pleurodesis as first-line definitive pleural intervention for management of dyspnea in patients with symptomatic MPE with known (or likely) suspected expandable lung, and no prior definitive therapy 1.

BiPAP settings typically start at inspiratory pressures (IPAP) of 8-12 cmH2O and expiratory pressures (EPAP) of 4-6 cmH2O, which can be titrated based on patient response and arterial blood gas results. However, caution is warranted as positive pressure ventilation could potentially worsen certain types of pleural effusions or cause complications in patients with untreated pneumothorax. The most recent and highest quality study on the management of malignant pleural effusions, published in 2018, provides guidance on the use of BiPAP and other interventions in the management of pleural effusion 1.

In terms of specific recommendations, the American Thoracic Society suggests that ultrasound imaging be used to guide pleural interventions, and that therapeutic pleural interventions should not be performed in asymptomatic patients with known or suspected MPE 1. The society also recommends the use of either an IPC or chemical pleurodesis as first-line definitive pleural intervention for management of dyspnea in patients with symptomatic MPE with known (or likely) suspected expandable lung, and no prior definitive therapy 1.

Overall, the use of BiPAP in the management of pleural effusion should be considered on a case-by-case basis, taking into account the individual patient's symptoms, underlying cause of the effusion, and response to treatment. The primary goal of treatment should be to address the underlying cause of the effusion and improve the patient's quality of life, rather than relying solely on respiratory support.

From the Research

Role of BiPAP in Managing Pleural Effusion

• The provided studies do not directly discuss the role of BiPAP (Bilevel Positive Airway Pressure) in managing patients with pleural effusion 2, 3, 4, 5.
• However, one study mentions the use of continuous positive airway pressure (CPAP) in drainage of pleural effusion, which is related to BiPAP 6.
• The study on CPAP found that an educational intervention for health professionals was effective in implementing the use of CPAP in hospitalized patients with pleural effusion undergoing thoracic drainage 6.
• It can be inferred that non-invasive ventilation techniques like BiPAP or CPAP may be beneficial in managing patients with pleural effusion, especially in cases where drainage is required 6.
• Further research is needed to determine the specific role of BiPAP in managing pleural effusion, as the current evidence is limited and indirect 2, 3, 4, 5, 6.

Key Points

• Pleural effusion is a complex condition that requires careful diagnosis and management 2, 3, 4, 5.
• The treatment of pleural effusion depends on the underlying cause and may involve drainage, pleurodesis, or other interventions 2, 3, 4, 5.
• Non-invasive ventilation techniques like BiPAP or CPAP may be useful in managing patients with pleural effusion, but more research is needed to confirm this 6.