Why should a patient on BiPAP (Bilevel Positive Airway Pressure) be NPO (Nil Per Os)?

Why Patients on BiPAP Should Be NPO

Patients on BiPAP should be kept NPO (nil per os) primarily when pneumothorax is present, as BiPAP increases the risk of aspiration due to the positive pressure delivered through the mask, which can force gastric contents into the airway if vomiting occurs. 1

Rationale for NPO Status with BiPAP

Risk of Aspiration

• BiPAP therapy delivers positive pressure through a face mask, which can:
  • Increase gastric distention
  • Potentially force gastric contents into the airway if vomiting occurs
  • Create a risk of aspiration pneumonia if the patient has impaired swallowing function

Specific Clinical Scenarios Requiring NPO Status

1. Pneumothorax

   • The American Journal of Respiratory and Critical Care Medicine explicitly recommends that "BiPAP should be withheld from patients with pneumothorax as long as the pneumothorax is present" 2
   • This is to prevent progression of the pneumothorax due to positive pressure ventilation

2. Massive Hemoptysis

   • BiPAP should be withheld from patients with massive hemoptysis 1
   • The positive pressure could potentially worsen bleeding

3. Impaired Level of Consciousness

   • Patients with severely depressed mental status are at higher risk of aspiration
   • This represents a relative contraindication to BiPAP therapy 1

4. Copious Secretions

   • Patients with excessive secretions may have difficulty managing their airway
   • This represents another contraindication to BiPAP therapy 1

Exceptions to NPO Status

Not all patients on BiPAP necessarily require NPO status. The decision should be based on:

1. Patient's Condition

   • Hemodynamically stable patients with preserved swallowing function may tolerate oral intake
   • Patients using BiPAP only during sleep may eat during the day when not on the device

2. Risk vs. Benefit Assessment

   • Prolonged NPO status can lead to:
   • Poor nutritional outcomes
   • Longer hospital stays
   • Decline in swallowing function 3

Clinical Considerations for BiPAP Management

Patient Monitoring

• Continuous oxygen saturation monitoring is essential for patients on BiPAP 1
• Regular assessment of respiratory status and airway clearance

Positioning

• Elevating the head of the bed (if not contraindicated) can help reduce the risk of aspiration 1
• A postoperative positioning in a head-elevated, semi-seated position prevents further development of atelectasis and may improve oxygenation 2

Secretion Management

• Teaching patients strategies to improve airway clearance and how to employ them early and aggressively 1
• Consider assisted cough technologies for patients with difficulty clearing secretions

Conclusion

While BiPAP therapy is valuable for treating respiratory failure, the risk of aspiration necessitates careful consideration of NPO status, particularly in patients with pneumothorax, massive hemoptysis, impaired consciousness, or copious secretions. The decision should balance the risks of aspiration against the potential negative consequences of prolonged NPO status, such as poor nutritional outcomes and decline in swallowing function.