BiPAP Use in Patients with Chest Tubes
BiPAP should be withheld from patients with pneumothorax as long as the pneumothorax is present, including patients with chest tubes. 1
Rationale and Evidence
The American Thoracic Society and British Thoracic Society guidelines clearly indicate that pneumothorax is a contraindication to BiPAP therapy 2. This recommendation is based on the concern that positive pressure ventilation could potentially worsen an existing pneumothorax or impair healing.
According to the Cystic Fibrosis Pulmonary Guidelines on pneumothorax management:
- For patients with small pneumothorax using BiPAP as chronic therapy, BiPAP should be discontinued as long as the pneumothorax is present (median rating 8, good consensus) 1
- For patients with large pneumothorax using BiPAP as chronic therapy, BiPAP should be discontinued as long as the pneumothorax is present (median rating 8, good consensus) 1
Clinical Considerations
Chest Tubes and BiPAP
- The presence of a chest tube does not automatically make BiPAP safe in a patient with pneumothorax
- Even with chest tube drainage, positive pressure ventilation can potentially:
- Impede lung re-expansion
- Increase air leak through the damaged pleura
- Prolong healing time
- Risk tension pneumothorax if the chest tube becomes occluded
Special Circumstances
- In cases where a patient absolutely requires ventilatory support and has a chest tube in place:
- Consider conventional mechanical ventilation with careful monitoring
- If BiPAP must be used (e.g., in a DNI patient), use the lowest effective pressures
- Ensure proper chest tube function and drainage
- Provide continuous monitoring for worsening pneumothorax
Alternatives to Consider
- Oxygen therapy via nasal cannula or mask
- Positioning (head of bed elevation)
- Pharmacological management of underlying condition
- Invasive mechanical ventilation if respiratory failure progresses
Post-Resolution Considerations
After pneumothorax resolution:
- The guidelines recommend not flying on a plane for 2 weeks after pneumothorax resolution 1
- Avoid lifting weights (>5 pounds) for 2 weeks after resolution 1
- Avoid spirometry for 2 weeks after resolution 1
- Consider gradual reintroduction of BiPAP if needed for chronic therapy
Conclusion
The evidence strongly supports withholding BiPAP therapy in patients with pneumothorax, regardless of chest tube placement. This recommendation is based on expert consensus from respiratory and thoracic societies, prioritizing patient safety and optimal healing of the pneumothorax.