When to start BiPAP (Bi-level Positive Airway Pressure) therapy?

From the Guidelines

BiPAP therapy should be started in patients with acute hypercapnic respiratory failure, severe respiratory distress, and persistent hypercapnia despite optimal medical therapy.

Indications for BiPAP Therapy

• Patients with severe respiratory distress, defined as a respiratory rate >25 breaths/min and SpO2 <90% 1
• Patients with acute hypercapnic respiratory failure, characterized by a pH <7.35 and pCO2 >6.5 kPa despite optimal medical therapy 1
• Patients with obesity hypoventilation syndrome (OHS) and concomitant severe obstructive sleep apnea (OSA) who have not responded to CPAP therapy 1
• Patients with hypoventilation, either during sleep or while awake, who require support with noninvasive positive pressure ventilation (NIV) 1

Key Considerations

• BiPAP therapy should be initiated as soon as possible in patients with respiratory distress and hypercapnia to decrease respiratory distress and reduce the rate of mechanical endotracheal intubation 1
• The use of BiPAP should be audited regularly to maintain standards, and the practice should not delay escalation to invasive mechanical ventilation (IMV) when necessary 1
• Clinical assessment of respiratory status, both asleep and awake, should be performed at each medical visit, and polysomnography should be performed when clinically indicated to assess respiratory function during sleep 1

From the Research

Indications for BiPAP Therapy

The decision to start BiPAP (Bi-level Positive Airway Pressure) therapy depends on various factors, including the patient's medical condition and response to other treatments. Some studies suggest that BiPAP can be effective in treating patients with:

• Obstructive sleep apnea (OSA) who are poorly compliant with CPAP therapy or have associated hypoventilation 2
• End-stage cystic fibrosis patients awaiting lung transplantation, as it can improve their respiratory status and provide long-term respiratory comfort and stability 3
• Patients with chronic obstructive pulmonary disease (COPD) and acute respiratory failure, as it can reduce cardiac arrhythmias and improve blood gas parameters 4
• Patients with type II respiratory failure due to acute exacerbation of COPD, although more research is needed to determine its therapeutic efficacy 5

Patient Selection

The selection of patients for BiPAP therapy should be based on individual assessment, taking into account their specific medical condition, symptoms, and response to other treatments. Patients who may benefit from BiPAP therapy include:

• Those with OSA who have failed CPAP therapy or have associated hypoventilation 2
• End-stage cystic fibrosis patients with respiratory decompensation 3
• Patients with COPD and acute respiratory failure who have cardiac arrhythmias or require non-invasive ventilation 4
• Patients with type II respiratory failure due to acute exacerbation of COPD, although further research is needed to confirm its effectiveness 5

Timing of BiPAP Initiation

The timing of BiPAP initiation depends on the patient's medical condition and the severity of their symptoms. BiPAP can be initiated:

• In patients with OSA who have failed CPAP therapy or have associated hypoventilation, as an alternative treatment option 2
• In end-stage cystic fibrosis patients awaiting lung transplantation, as soon as possible to improve their respiratory status and provide long-term respiratory comfort and stability 3
• In patients with COPD and acute respiratory failure, as soon as cardiac arrhythmias or respiratory failure are diagnosed 4
• In patients with type II respiratory failure due to acute exacerbation of COPD, although the optimal timing of BiPAP initiation in this population is still unclear 5