What are the guidelines for titrating Non-Invasive Ventilation (NIV) and Continuous Positive Airway Pressure (CPAP)?

Guidelines for Titrating Non-Invasive Ventilation (NIV) and Continuous Positive Airway Pressure (CPAP)

NIV and CPAP titration should follow standardized protocols with specific pressure settings based on the underlying condition, with CPAP starting at 8-10 cmH2O for most conditions and NIV starting with minimum IPAP of 8 cmH2O and EPAP of 4 cmH2O, with pressure support of at least 4 cmH2O. 1

Initial Settings and Titration Parameters

CPAP Titration

• Start with a minimum pressure of 4 cmH2O for both pediatric and adult patients 2
• For COVID-19 and hypoxemic respiratory failure, start CPAP at 10 cmH2O with FiO2 0.6 1
• Maximum recommended CPAP pressure is 15 cmH2O for patients <12 years and 20 cmH2O for patients ≥12 years 2
• Increase CPAP by 1-2 cmH2O increments at intervals no shorter than 5 minutes 1, 2
• For acute pulmonary edema, the most common CPAP level is 10 cmH2O 3
• CPAP can be increased to 12-15 cmH2O with FiO2 0.6-1.0 if further escalation is needed 1
• In some conditions (e.g., COVID-19), CPAP pressures might be increased up to 15-20 cmH2O if escalation is needed 1

NIV/BPAP Titration

• Minimum starting IPAP and EPAP should be 8 cmH2O and 4 cmH2O, respectively 1
• Minimum starting pressure support (IPAP-EPAP) should be 4 cmH2O 1
• Maximum pressure support should be 20 cmH2O 1
• Maximum IPAP should be 20 cmH2O for patients <12 years and 30 cmH2O for patients ≥12 years 1
• Minimum and maximum incremental changes in pressure support during NIV titration should be 1 and 2 cmH2O, respectively 1
• For high-intensity NIV in COPD, higher inspiratory pressures and respiratory rates may be used to normalize PaCO2 1

Titration Goals and Monitoring

Oxygenation Targets

• SpO2 should generally be maintained above 90% and no higher than 96% 1
• For patients with strong respiratory drive (low/normal PaCO2), target SpO2 of 94% 1
• For patients with acute or chronic type 2 respiratory failure, titrate SpO2 to 88-92% 1
• Australian guidelines suggest maintaining SpO2 of at least 92% 1

Ventilation Assessment

• Monitor airflow, tidal volume, leak, and delivered pressure signals 1
• Use airflow signal to detect apnea and hypopnea 1
• Use tidal volume signal and respiratory rate to assess ventilation 1
• Consider transcutaneous or end-tidal PCO2 monitoring to adjust NIV settings if adequately calibrated 1
• Respiratory function of patients on chronic NIV should be assessed with measures of oxygenation and ventilation (arterial blood gas, end-tidal CO2, transcutaneous PCO2) on a regular follow-up basis 1

Titration Quality Assessment

Optimal Titration

• An optimal NIV titration reduces the AHI to <5 events/hour for at least 15 minutes in NREM sleep in the supine position and during REM sleep 1
• Eliminates obstructive apneas, hypopneas, RERAs, and snoring 1
• Shows SpO2 above 90% (or target range based on condition) 1
• Shows stable or improved ventilation with acceptable tidal volumes 1

Good Titration

• Reduces the AHI to ≤10 events/hour or by 50% if the baseline AHI was <15 events/hour 1
• Includes periods of REM and supine sleep with good control of respiratory events 1

Indications for Repeat Titration

• Initial titration does not achieve a grade of optimal, good, or adequate 1
• Less than 3 hours of sleep was recorded during the titration 1
• Respiratory function or sleep quality deteriorates in a patient on chronic NIV treatment 1

Special Considerations for Different Conditions

COVID-19 Patients

• For patients with lower oxygen requirements (FiO2 <0.4), low-flow CPAP is suitable 1
• CPAP should be set to 10 cmH2O with FiO2 0.6 for oriented patients who can tolerate a well-fitted mask 1
• Close monitoring is essential - evaluate patient condition within 1-2 hours after starting NIV 1
• Consider escalation to invasive ventilation if no improvement or worsening within 1-2 hours 1

COPD Patients

• Consider NIV with targeted normalization of PaCO2 in patients with hypercapnic COPD 1
• High-intensity NIV with higher inspiratory pressures and respiratory rates may be beneficial 1
• BiPAP is preferred over CPAP for patients with type 2 respiratory failure 1
• For patients with evidence of acute or chronic type 2 respiratory failure, titrate SpO2 to 88-92% 1

Common Pitfalls and Practical Considerations

• Mask leaks can significantly reduce effectiveness of therapy - ensure proper mask fitting before titration 1
• Patient discomfort at higher pressures may lead to poor adherence - consider starting at lower pressures and gradually increasing 1
• Inadequate humidification can cause nasal congestion and mouth dryness - heated humidification should be available 1
• Failure to monitor for patient-ventilator asynchrony can lead to ineffective ventilation 4
• Delayed recognition of NIV failure may increase mortality - establish clear criteria for escalation to invasive ventilation 1
• Starting at too low pressures may prolong titration time and reduce success rates - consider using prediction equations for initial settings 5

Follow-up Recommendations

• Close follow-up after initiation of NIV by appropriately trained healthcare providers is essential 1
• Use objective adherence data when available to establish effective utilization patterns 1
• Address problems including NIV side effects and interface issues promptly 1
• Ensure equipment is maintained in good repair and disposable equipment is changed on a regular schedule 1
• Assess respiratory function regularly with measures of oxygenation and ventilation 1
• Consider repeat titration if clinical deterioration occurs 1