Can BiPAP (Bilevel Positive Airway Pressure) be used during sleep?

BiPAP Therapy During Sleep

BiPAP (Bilevel Positive Airway Pressure) therapy is specifically designed for use during sleep and is an effective treatment for various sleep-related breathing disorders, including obstructive sleep apnea (OSA). 1

Indications for BiPAP During Sleep

BiPAP is particularly indicated in the following situations:

• When patients are intolerant of high CPAP pressures (typically >15 cm H₂O) 1
• When patients continue to have obstructive respiratory events at 15 cm H₂O of CPAP 1
• For patients requiring PAP treatment with pressures higher than 20 cm H₂O, which standard CPAP devices cannot deliver 1
• For patients with central sleep apnea or Cheyne-Stokes breathing patterns 2, 3
• For patients with neuromuscular disorders or hypoventilation syndromes 4

Initial Settings and Setup

When initiating BiPAP therapy for sleep, the American Academy of Sleep Medicine recommends:

• Starting with minimum settings: IPAP of 8 cm H₂O and EPAP of 4 cm H₂O 1
• Maintaining a minimum IPAP-EPAP differential of 4 cm H₂O 1
• Not exceeding a maximum IPAP-EPAP differential of 10 cm H₂O to avoid patient discomfort 1
• Using a ramp time of 5 minutes per pressure adjustment for BiPAP initiation 1

Pressure Titration Protocol

For optimal therapy during sleep, pressures should be titrated as follows:

• Increase IPAP by 1-2 cm H₂O every 5 minutes to improve ventilation 1
• Increase EPAP by 1 cm H₂O every 5 minutes to eliminate obstructive events 1
• Maximum IPAP is 30 cm H₂O for adults (≥12 years) and 20 cm H₂O for children (<12 years) 1
• Maximum EPAP is typically 8-10 cm H₂O, adjusted based on patient tolerance 1

Optimizing Comfort and Compliance

To ensure patients can successfully use BiPAP while sleeping:

• Proper mask fitting is crucial to minimize leak and maximize comfort 1
• Allow patients to become comfortable with the mask and airflow at low initial pressures before beginning titration 1
• Provide comprehensive patient education on the purpose, goals, and potential side effects of BiPAP therapy 1
• Adjust rise time (time from EPAP to IPAP) for patient comfort:
  • Shorter rise times (100-400 ms) for patients with obstructive disease
  • Longer rise times (300-600 ms) for patients with restrictive disease 1

Monitoring and Titration Endpoints

Continue titration during sleep until:

• Respiratory events are eliminated (RDI <5 per hour for at least 15 minutes) 1
• Maximum recommended pressures are reached 1
• Patient has achieved 30 minutes without breathing events, including during supine REM sleep 1

Follow-up and Compliance Monitoring

• Initial follow-up is recommended during the first few weeks to establish utilization pattern and provide remediation if needed 4
• Longer-term follow-up is recommended yearly or as needed to address mask, machine, or usage problems 4
• CPAP/BiPAP usage should be monitored objectively to help assure utilization 4

Common Pitfalls and Solutions

1. Mask leaks: Refit or change mask type when significant leaks occur, as they can compromise therapy effectiveness 1

2. Pressure intolerance: If the patient awakens and complains that pressure is too high, decrease to a lower pressure that allows return to sleep 1

3. Inadequate ventilation: Consider switching to ST (spontaneous-timed) mode with backup rate if central apneas emerge or if adequate ventilation is not achieved with maximum pressure support 1

4. Contraindications: BiPAP therapy is contraindicated in patients with respiratory arrest, inability to protect airway, severe facial trauma or burns, and recent facial, esophageal, or gastric surgery 1

BiPAP therapy is not only safe and effective for use during sleep, but it is specifically designed to be used while the patient is sleeping to treat various sleep-related breathing disorders. The American Academy of Sleep Medicine guidelines provide clear protocols for initiating, titrating, and monitoring BiPAP therapy during sleep to ensure optimal treatment outcomes.