What are the standard settings for auto BiPAP (Bilevel Positive Airway Pressure)?

Standard Settings for Auto BiPAP

The recommended standard settings for auto BiPAP include a minimum IPAP of 8 cm H₂O, minimum EPAP of 4 cm H₂O, maximum IPAP of 30 cm H₂O for adults (20 cm H₂O for children <12 years), and a pressure support differential of 4-10 cm H₂O. 1

Initial Settings

Pressure Parameters

• Minimum IPAP: 8 cm H₂O 1
• Minimum EPAP: 4 cm H₂O 1
• Maximum IPAP: 30 cm H₂O for patients ≥12 years; 20 cm H₂O for patients <12 years 1
• Pressure Support (IPAP-EPAP differential):
  • Minimum: 4 cm H₂O 1
  • Maximum: 10 cm H₂O 1

Mode Selection

• Mode: Spontaneous-timed (ST) mode is recommended for most patients, especially those with:
  • Central hypoventilation
  • Significant central apneas
  • Inappropriately low respiratory rate
  • Muscle weakness affecting reliable triggering 1

Backup Rate Settings

• Starting backup rate: Equal to or slightly less than spontaneous sleeping respiratory rate (minimum 10 breaths per minute) 1
• Inspiratory time (IPAP time): Set based on respiratory rate and patient comfort 1

Titration Algorithm

For Obstructive Events

1. For apneas: Increase both IPAP and EPAP by ≥1 cm H₂O if ≥2 obstructive apneas are observed in adults (≥1 in children <12 years) 1
2. For hypopneas: Increase IPAP by ≥1 cm H₂O if ≥3 hypopneas are observed in adults (≥1 in children <12 years) 1
3. For RERAs: Increase IPAP by ≥1 cm H₂O if ≥5 RERAs are observed in adults (≥3 in children <12 years) 1
4. For snoring: Increase IPAP by ≥1 cm H₂O if ≥3 minutes of loud or unambiguous snoring is observed in adults (≥1 minute in children <12 years) 1

For Hypoventilation

• Increase pressure support if tidal volume is low (<6-8 mL/kg) 1
• Increase pressure support if arterial PCO₂ remains elevated above goal for ≥10 minutes 1
• Consider increasing backup rate by 1-2 breaths per minute every 10 minutes if ventilation remains inadequate 1

Adjustment Protocol

• Make pressure adjustments at intervals no shorter than 5 minutes 1
• Allow at least 30 minutes without respiratory events before considering settings optimized 1
• "Exploration" of IPAP above the pressure that controls respiratory events should not exceed 5 cm H₂O 1

Troubleshooting Common Issues

Patient Discomfort

• If patient complains pressure is too high: Decrease to a comfortable level that allows return to sleep 1, 2
• Consider adjusting rise time for comfort:
  • Shorter rise times (100-400 ms) for obstructive airway disease
  • Longer rise times (300-600 ms) for restrictive disease 2

Central Apneas

• If treatment-emergent central apneas occur: Consider decreasing IPAP or setting BiPAP in spontaneous-timed mode with backup rate 1

Mask Issues

• Perform mask refit or change mask type if significant unintentional leak occurs 2
• Consider oronasal mask or chin strap if mouth leak causes significant symptoms 2

Special Considerations

Humidification

• Add heated humidification for patients with nasal/pharyngeal dryness, congestion, or irritation 2

Monitoring

• Schedule periodic reassessments as appropriate to disease stage 2
• Monitor for development of daytime hypoventilation, which may necessitate around-the-clock ventilation 2

Auto BiPAP is particularly beneficial when fixed CPAP or BiPAP is ineffective or poorly tolerated. The device automatically adjusts pressures within the set parameters to maintain airway patency while optimizing comfort and efficacy.