What is the preferred initial management between BiPAP (Bilevel Positive Airway Pressure) and ETT (Endotracheal Tube) for a near drowning patient?

BiPAP vs ETT for Near Drowning: Initial Management Approach

For near drowning patients, endotracheal intubation (ETT) should be performed immediately for patients who present with apnea, coma, persistent or increasing hypercapnia, exhaustion, severe distress, or depression of mental status, while BiPAP should be reserved for alert patients with adequate spontaneous respiratory effort who have respiratory symptoms but do not meet intubation criteria. 1, 2

Initial Assessment Algorithm

1. Assess Respiratory Status:

   • Is the patient breathing? If not, immediately provide rescue breaths and proceed to ETT
   • Is the patient conscious and alert? If not, proceed to ETT
   • Does the patient have adequate spontaneous respiratory effort? If not, proceed to ETT

2. Evaluate Clinical Presentation:

   • Indications for Immediate ETT:

     • Apnea or severely inadequate respiratory effort
     • Coma or significantly depressed mental status
     • Persistent or worsening hypercapnia
     • Severe respiratory distress or exhaustion
     • Inability to protect airway (e.g., frequent vomiting)
     • Hemodynamic instability

   • Potential BiPAP Candidates:

     • Alert and cooperative
     • Adequate spontaneous breathing
     • Respiratory distress with hypoxemia despite supplemental oxygen
     • Hemodynamically stable
     • Able to protect airway

Evidence-Based Management Considerations

ETT Advantages in Near Drowning

• Provides definitive airway protection against aspiration of water/vomitus
• Allows for effective pulmonary toilet and secretion clearance
• Facilitates precise control of ventilation parameters to manage the noncardiogenic pulmonary edema common in drowning 3
• Enables lung-protective ventilation strategies with controlled tidal volumes (6-8 mL/kg) 1
• Prevents further aspiration, which is critical as vomiting occurs in the majority of drowning victims requiring resuscitation 2

BiPAP Considerations

• May be appropriate for less severe cases with respiratory distress but adequate spontaneous breathing 4, 5
• Can potentially prevent the need for intubation in select patients 4
• Should be discontinued if there is any bleeding (as noted in hemoptysis guidelines) 1
• Requires the patient to be alert and cooperative 1
• Carries risk of aspiration if the patient vomits (common in near drowning)

Important Clinical Cautions

• Do NOT delay definitive airway management in patients with significant respiratory compromise
• Do NOT attempt to remove water from airways by abdominal thrusts or Heimlich maneuver (Class III, LOE C) 2
• Be prepared for vomiting during resuscitation, which occurs in most victims requiring resuscitation 2
• All near drowning victims requiring any form of resuscitation should be transported to a hospital for evaluation and monitoring for at least 4-6 hours 2
• Premature ventilatory weaning may cause return of pulmonary edema with need for re-intubation 3

Ventilation Strategies

If Using ETT:

• Use lower tidal volumes (6-8 mL/kg predicted body weight)
• Target plateau pressure <30 cmH2O
• Consider PEEP titration based on FiO2 requirements
• Monitor for auto-PEEP and barotrauma
• Consider permissive hypercapnia if hemodynamically stable 1

If Using BiPAP:

• Start with inspiratory pressure of 8-12 cmH2O and expiratory pressure of 3-7 cmH2O 4
• Titrate to improve oxygenation while maintaining patient comfort
• Monitor closely for deterioration requiring escalation to ETT
• Ensure high-concentration oxygen delivery

Remember that the primary cause of death from drowning is insufficient oxygen delivery to the heart and brain, and prompt restoration of oxygen delivery is paramount 1. The decision between BiPAP and ETT should prioritize the intervention most likely to rapidly reverse hypoxemia while protecting the airway in the individual patient's clinical context.