What are the optimal settings for Bi-level Positive Airway Pressure (BIPAP) therapy, including fraction of inspired oxygen (FiO2), for a patient experiencing a Chronic Obstructive Pulmonary Disease (COPD) exacerbation?

From the Guidelines

For a patient experiencing a Chronic Obstructive Pulmonary Disease (COPD) exacerbation, I recommend starting BiPAP with an inspiratory positive airway pressure (IPAP) of 10-12 cmH2O and expiratory positive airway pressure (EPAP) of 4-5 cmH2O, and setting the fraction of inspired oxygen (FiO2) to achieve an oxygen saturation target of 88-92%. This approach is based on the most recent and highest quality evidence from the BTS guideline for oxygen use in adults in healthcare and emergency settings 1 and the BTS/ICS guideline for the ventilatory management of acute hypercapnic respiratory failure in adults 1.

Key Considerations for BiPAP Settings

• The initial FiO2 should be set at 28-35% to target the recommended oxygen saturation range of 88-92% 1.
• The pressure gradient (difference between IPAP and EPAP) should be at least 5 cmH2O to provide adequate ventilatory support.
• If the patient remains hypercapnic or shows signs of increased work of breathing, gradually increase IPAP by 2-3 cmH2O increments to a maximum of 20-25 cmH2O as tolerated.
• Respiratory rate backup should be set at 12-15 breaths per minute.
• Closely monitor arterial blood gases after 1-2 hours of therapy to assess response and adjust settings accordingly.

Monitoring and Adjustments

• Recheck blood gases after 30–60 min (or if there is evidence of clinical deterioration) for all patients with COPD or other risk factors for hypercapnic respiratory failure even if the initial PCO2 measurement was normal 1.
• If the PCO2 is raised but pH is ≥7.35 and/or a high bicarbonate level (>28 mmol/L), maintain a target range of 88–92% for these patients.
• Ensure the mask fits properly to minimize air leaks and maximize patient comfort and compliance with the therapy.

Rationale

This approach helps reduce work of breathing, improves alveolar ventilation, and decreases CO2 retention while avoiding excessive oxygen that could worsen hypercapnia in COPD patients, as supported by the guidelines 1. By following these recommendations, healthcare providers can optimize BiPAP therapy for patients with COPD exacerbations, ultimately improving morbidity, mortality, and quality of life outcomes.

From the Research

Optimal Settings for Bi-level Positive Airway Pressure (BIPAP) Therapy

• The optimal settings for BIPAP therapy in patients with Chronic Obstructive Pulmonary Disease (COPD) exacerbation are not explicitly stated in the provided studies, but the fraction of inspired oxygen (FiO2) is recommended to be less than 0.28, aiming for a saturation (SpO2) of 88-92% until arterial blood gas analysis is available 2.
• The use of BIPAP in COPD exacerbations has been shown to be effective in improving gas exchange and reducing the need for tracheal intubation 3, 4.
• The settings for BIPAP should be individualized and titrated to achieve the desired clinical response, with the goal of improving oxygenation and reducing respiratory distress 5, 3.

Fraction of Inspired Oxygen (FiO2)

• The recommended FiO2 for COPD exacerbations is less than 0.28, with the goal of achieving a SpO2 of 88-92% 6, 2.
• High-flow oxygen therapy is often used in the initial treatment of COPD exacerbations, but it is important to titrate the FiO2 to avoid hypercapnia 2.
• The use of arterial blood gas analysis is recommended to guide oxygen therapy and adjust the FiO2 as needed 6.

Clinical Applications of BIPAP

• BIPAP is a useful therapy for patients with acute respiratory failure due to COPD exacerbation, particularly in settings where invasive ventilation is not easily available 3.
• The sequential use of noninvasive pressure support ventilation, including BIPAP, has been shown to be effective in managing patients with acute exacerbations of COPD 4.
• New modalities of noninvasive ventilation, including adaptive servo-ventilation and proportional assist ventilation, may improve patient comfort and patient-ventilator interactions 5.