Can a patient with pneumothorax be placed on BiPAP (Bilevel Positive Airway Pressure) or mechanical ventilation?

Management of Patients with Pneumothorax on BiPAP or Mechanical Ventilation

BiPAP should be withheld from patients with pneumothorax as long as the pneumothorax is present. 1

Rationale for Withholding BiPAP in Pneumothorax

The cystic fibrosis pulmonary guidelines provide clear recommendations regarding the use of BiPAP in patients with pneumothorax. The expert panel determined that withholding BiPAP from patients with pneumothorax is acceptable management in many circumstances, regardless of pneumothorax size 1. This recommendation is based on the concern that positive pressure ventilation may cause progression of the pneumothorax.

This concern is supported by research evidence showing that:

• Positive airway pressure can cause barotrauma leading to pneumothorax in patients with underlying lung disease 2
• Pneumothorax is a potentially lethal complication associated with mechanical ventilation 3
• Even relatively low pressures (4-8 cm H2O) have been reported to cause pneumothorax in susceptible individuals 2

Special Considerations for Critical Patients

If a patient requires respiratory support despite having a pneumothorax, the following approach should be taken:

• Observation in an intensive care unit setting is appropriate when withholding BiPAP 1
• Chest tube placement should be performed prior to any consideration of mechanical ventilation 3
• If mechanical ventilation is absolutely necessary, use the lowest possible pressures to minimize risk of pneumothorax expansion 4

Management Algorithm for Pneumothorax Patients Requiring Ventilatory Support

1. First step: Place chest tube to evacuate pneumothorax before considering any positive pressure ventilation
2. If respiratory support is essential:
   • Monitor in ICU setting
   • Use lowest effective pressures if mechanical ventilation is required
   • Consider surgical pleurodesis for recurrent pneumothorax before resuming BiPAP 1

Resuming BiPAP After Pneumothorax Resolution

After complete resolution of pneumothorax:

• Wait at least 2 weeks before resuming BiPAP therapy 1
• Consider lower pressure settings when restarting BiPAP to reduce risk of recurrence 2
• Monitor closely for signs of recurrent pneumothorax

Pitfalls to Avoid

• Do not continue BiPAP in a patient with known pneumothorax, as this may worsen the condition 1, 3
• Do not use high peak inspiratory pressures in patients with history of pneumothorax, as this significantly increases risk of recurrence 4
• Do not delay chest tube placement in mechanically ventilated patients with pneumothorax due to high risk of tension pneumothorax 3

Evidence Quality Assessment

The recommendation to withhold BiPAP in patients with pneumothorax comes from the 2010 Cystic Fibrosis Foundation Pulmonary Guidelines 1, which represents expert consensus. While not based on randomized controlled trials, this recommendation achieved good consensus among the expert panel and aligns with the physiological understanding of pneumothorax progression under positive pressure.

Research studies further support this cautious approach, demonstrating that positive pressure ventilation increases the risk of pneumothorax, especially in patients with underlying lung disease 3, 2, 4.