From the Guidelines
For COPD exacerbation, initial BiPAP settings should include an inspiratory positive airway pressure (IPAP) of 10-14 cmH2O and expiratory positive airway pressure (EPAP) of 4-6 cmH2O, with a strong recommendation for the use of noninvasive mechanical ventilation in patients with acute or acute-on-chronic respiratory failure 1. The optimal BiPAP settings for a patient experiencing COPD exacerbation can be determined by considering the following factors:
- Inspiratory positive airway pressure (IPAP): 10-14 cmH2O
- Expiratory positive airway pressure (EPAP): 4-6 cmH2O
- Backup rate: 12-15 breaths per minute
- Titration of IPAP: upward by 2-3 cmH2O increments every 5-10 minutes as needed to reduce work of breathing
- Target tidal volumes: 6-8 mL/kg ideal body weight
- Maximum IPAP: typically 20-25 cmH2O
- Supplemental oxygen: added to maintain SpO2 between 88-92% The use of noninvasive mechanical ventilation, such as BiPAP, is recommended for patients with COPD exacerbation associated with acute or acute-on-chronic respiratory failure, as it can reduce the work of breathing, improve alveolar ventilation, and overcome auto-PEEP in COPD patients 1. Some key considerations when using BiPAP in COPD patients include:
- Ensuring a well-fitting mask to prevent air leaks
- Monitoring for complications such as facial skin breakdown, gastric distention, and aspiration risk
- Considering sedation only if absolutely necessary for mask tolerance, using minimal doses
- Monitoring for improvement in respiratory rate, heart rate, pH, and PaCO2 within 1-2 hours It is also important to note that the pressure support (difference between IPAP and EPAP) helps overcome airway resistance during inspiration, while EPAP helps maintain airway patency and improves oxygenation 1.
From the Research
Optimal BIPAP Settings for COPD Exacerbation
The optimal BIPAP settings for a patient experiencing Chronic Obstructive Pulmonary Disease (COPD) exacerbation are not explicitly stated in the provided studies. However, the following information can be gathered:
- A study from 2 found that Bi-pap administered by nasal mask was effective in reducing respiratory rate, heart rate, and PaCO2, and increasing PaO2 and pH in patients with acute respiratory failure due to acute exacerbation of COPD.
- The same study 2 used Bi-pap settings with an unspecified pressure level, but another study from 3 used BiPAP with a higher pressure (Phigh) of 15 cmH2O and a lower pressure (Plow) of 5 cmH2O.
- A study from 4 used mask-applied continuous positive airway pressure (CPAP) with a pressure level of +5 cmH2O, which may not be directly applicable to BIPAP settings.
- A study from 5 used non-invasive home mechanical ventilation (BIPAP) during nocturnal rest in COPD patients with hypercapnia, but the specific pressure settings were not mentioned.
Key Findings
- The use of Bi-pap or non-invasive mechanical ventilation can be beneficial in reducing respiratory rate, heart rate, and PaCO2, and increasing PaO2 and pH in patients with acute respiratory failure due to acute exacerbation of COPD 2.
- The optimal pressure settings for BIPAP in COPD exacerbation are not clearly established, but a study used Phigh of 15 cmH2O and Plow of 5 cmH2O 3.
- Non-invasive mechanical ventilation, including BIPAP, can reduce hospital admissions due to worsening of underlying respiratory pathology in COPD patients 5.
BIPAP Settings Considerations
- The choice of BIPAP settings may depend on individual patient factors, such as the severity of COPD, the presence of hypercapnia, and the patient's tolerance to the therapy.
- Further research is needed to determine the optimal BIPAP settings for patients with COPD exacerbation.
- The studies provided do not offer a clear consensus on the optimal BIPAP settings, highlighting the need for more research in this area 6, 3, 4, 2, 5.