Why BiPAP Should Not Be Used in Pneumothorax
BiPAP should be withheld from patients with pneumothorax as long as the pneumothorax is present due to the risk of pneumothorax progression and worsening of the condition. 1
Mechanism and Rationale
BiPAP (Bilevel Positive Airway Pressure) delivers positive pressure during both inspiration and expiration, which can have detrimental effects in pneumothorax:
- The positive pressure can force more air into the pleural space through the existing air leak
- This increased pressure can expand an existing pneumothorax
- The pressure gradient created can prevent spontaneous healing of the pleural tear
Evidence-Based Recommendations
The American Journal of Respiratory and Critical Care Medicine guidelines clearly state that BiPAP should be withheld from patients with pneumothorax regardless of size 1. This recommendation achieved good consensus among experts with a median rating of 8 (on a scale of 0-10) for both small and large pneumothoraces.
Key points from the guidelines:
- BiPAP discontinuation is recommended for the entire duration that pneumothorax is present
- This applies to both small and large pneumothoraces
- The recommendation applies even to patients who regularly use BiPAP for chronic conditions
Case Reports Supporting the Recommendation
There have been documented cases of pneumothorax occurring as a complication of positive airway pressure therapy. A 2023 case report described a 72-year-old male with COPD who developed pneumothorax after using automatic PAP therapy, even at relatively low pressures of 4-8 cm H2O 2. This highlights that even modest positive pressure can trigger pneumothorax in susceptible individuals.
Management Considerations
When a patient who requires BiPAP develops a pneumothorax:
- Immediately discontinue BiPAP therapy
- Consider observation in an intensive care unit for patients who depend on BiPAP for respiratory support 1
- Treat the pneumothorax appropriately (observation, chest tube drainage, etc.)
- Resume BiPAP only after complete resolution of the pneumothorax
- Consider using lower pressures when restarting BiPAP (as demonstrated in the case report where continuous PAP at 5 cm H2O was successfully used after pneumothorax resolution) 2
Post-Pneumothorax Precautions
After pneumothorax resolution, the guidelines recommend several precautions before resuming normal activities:
- Avoid air travel for at least 2 weeks
- Avoid lifting weights (>5 pounds) for 2 weeks
- Avoid performing spirometry for 2 weeks
- Consider gradual reintroduction of BiPAP with close monitoring if the patient requires it for chronic respiratory support
Common Pitfalls to Avoid
Continuing BiPAP despite pneumothorax: Even if a patient is dependent on BiPAP for respiratory support, continuing it during pneumothorax can worsen the condition and lead to tension pneumothorax.
Inadequate monitoring: Patients with pneumothorax who previously used BiPAP may experience respiratory deterioration when BiPAP is withheld. These patients require close monitoring, possibly in an ICU setting.
Premature resumption of BiPAP: Restarting BiPAP before complete resolution of pneumothorax can lead to recurrence or expansion of the pneumothorax.
BiPAP remains contraindicated in pneumothorax as it is listed among the absolute contraindications for non-invasive ventilation according to multiple guideline societies 3.