From the Guidelines
BiPAP is a highly effective treatment for hypercapnia, as it helps improve ventilation and reduce carbon dioxide levels in the blood, with the most recent and highest quality evidence supporting its use in patients with hypercapnic respiratory failure 1. The use of BiPAP in treating hypercapnia is supported by its ability to deliver two different pressure levels, a higher pressure during inhalation (IPAP) and a lower pressure during exhalation (EPAP), which helps improve tidal volume and reduce the work of breathing.
- Typical initial settings for BiPAP in patients with hypercapnia may include an IPAP of 12-16 cmH2O and an EPAP of 4-6 cmH2O, with adjustments made based on arterial blood gas results and patient comfort.
- BiPAP is particularly beneficial for hypercapnic respiratory failure associated with conditions like COPD exacerbations, obesity hypoventilation syndrome, and neuromuscular disorders, as it works by mechanically assisting breathing, which helps flush out excess CO2 from the lungs and improves gas exchange.
- The use of BiPAP can often allow patients to avoid endotracheal intubation while their underlying condition is treated, with patients typically using BiPAP continuously during acute hypercapnia, with gradual weaning as their condition improves, as recommended by the 2016 ESC guidelines for the diagnosis and treatment of acute and chronic heart failure 1.
- It is essential to monitor patients closely while on BiPAP, especially those with hypotension, as non-invasive positive pressure ventilation can reduce blood pressure and should be used with caution in these patients, with regular monitoring of blood pressure and adjustment of treatment as needed 1.
From the Research
BiPAP and Hypercapnia
- Bi-level Positive Airway Pressure (BiPAP) has been studied as a treatment for hypercapnia in patients with chronic obstructive pulmonary disease (COPD) 2, 3, 4, 5, 6.
- A study published in 2013 found that BiPAP with average volume assured pressure support (AVAPS) improved blood gas levels and reduced the need for intubation in patients with COPD and hypercapnic encephalopathy 2.
- Another study published in 2003 suggested that non-invasive positive pressure ventilation (NIPPV) may be beneficial for patients with stable COPD and hypercapnia, but the evidence was not conclusive 3.
- A 2017 systematic review and meta-analysis found that NIV with BiPAP decreased the risk of mortality and endotracheal intubation in patients with acute hypercapnic respiratory failure due to COPD exacerbation 4.
- A 2015 pilot study found that high-intensity non-invasive positive pressure ventilation (HI-NPPV) reduced PaCO2 levels and improved quality of life in stable hypercapnic COPD patients 5.
- A 2020 systematic review and meta-analysis found that home BiPAP was associated with lower risk of mortality, all-cause hospital admission, and intubation in patients with COPD and hypercapnia 6.
Mechanism of Action
- BiPAP works by providing two levels of air pressure, a higher pressure during inhalation and a lower pressure during exhalation, to help keep the airways open and improve breathing 2, 4.
- This can help reduce hypercapnia by increasing ventilation and improving gas exchange in the lungs 2, 4.