What are the guidelines for arranging BiPAP (Bilevel Positive Airway Pressure) or CPAP (Continuous Positive Airway Pressure) for patients requiring respiratory support at home?

Arranging BiPAP or CPAP for Patients at Home

For adults with obstructive sleep apnea (OSA) without significant comorbidities, initiate positive airway pressure therapy using either auto-adjusting PAP (APAP) at home or in-laboratory titration, with home APAP being preferred for faster, more convenient, and cost-effective treatment. 1

Patient Selection and Initial Assessment

Adults with OSA

• Either APAP or CPAP can be used for ongoing treatment of OSA in adults, as they show equivalent efficacy in adherence, sleepiness, and quality of life outcomes. 1
• Home APAP initiation is equally effective as in-laboratory titration for patients without significant comorbidities, with no clinically significant differences in adherence, sleepiness, or quality of life. 1

Exclusion Criteria for Home APAP Setup

Patients with the following conditions require in-laboratory titration or BiPAP consideration rather than simple home APAP:

• Congestive heart failure 1
• Chronic opiate use 1
• Significant lung disease (COPD, neuromuscular disease) 1
• Sleep-related oxygen requirements 1
• Hypoventilation syndromes 1
• Central sleep apnea syndromes 1

When to Choose BiPAP Over CPAP

Switch to BiPAP if the patient is uncomfortable or intolerant of high CPAP pressures (≥15 cm H₂O) or if obstructive respiratory events persist at maximum CPAP levels. 1, 2

BiPAP is specifically indicated for:

• Patients with OSA who cannot tolerate CPAP 2, 3
• Chronic alveolar hypoventilation 2
• Central sleep apnea not responding to CPAP 2
• Neuromuscular disorders (e.g., Duchenne muscular dystrophy) with nocturnal hypoventilation 1

Home Setup Requirements

Essential Components for Successful Home Initiation

Adequate patient education, proper mask fitting, and close follow-up by trained staff are mandatory prerequisites for home PAP setup. 1

The home setup must include:

• Mask fitting session at a sleep center before home use 1
• Education on PAP use by trained staff 1
• Optional daytime acclimatization to PAP at low pressures 1
• Objective monitoring capability (device data download) 1

Initial Pressure Settings

For CPAP:

• Start at 4-5 cm H₂O and titrate upward 1

For BiPAP:

• Minimum starting IPAP: 8 cm H₂O 1, 2
• Minimum starting EPAP: 4 cm H₂O 1, 2
• Minimum IPAP-EPAP differential: 4 cm H₂O 1
• Maximum IPAP-EPAP differential: 10 cm H₂O 1

Follow-Up Protocol

Critical Early Monitoring Period

Monitor clinical response and PAP usage data within the first few weeks, as this is the most vulnerable period for treatment failure. 1

Specific monitoring requirements:

• Objective PAP usage monitoring to ensure utilization 1
• Contact with healthcare providers during the first few weeks 1
• Skipping PAP use for ≥2 nights within the first week signals potential nonadherence and requires immediate intervention 1

Ongoing Assessment

For neuromuscular patients on home ventilation:

• Perform polysomnography with continuous CO₂ monitoring to assess adequacy of support 1
• Where polysomnography unavailable, use overnight pulse oximetry with continuous CO₂ monitoring 1
• Schedule periodic reassessment appropriate to disease stage 1
• Monitor for development of daytime hypoventilation requiring 24-hour ventilation 1

Special Populations

Pediatric and Neuromuscular Patients

Use nasal intermittent positive pressure ventilation (BiPAP or volume ventilator) to treat sleep-related upper airway obstruction and chronic respiratory insufficiency in patients with neuromuscular disorders like Duchenne muscular dystrophy. 1

Key considerations:

• CPAP has limited utility in neuromuscular patients and should only be used for isolated obstructive sleep apnea with normal nocturnal ventilation 1
• Never use oxygen alone to treat sleep-related hypoventilation without ventilatory assistance 1
• Negative-pressure ventilators should be used with caution due to risk of precipitating upper airway obstruction 1

Patients with Down Syndrome

• Specific anatomical features (flat nasal bridge, macroglossia, midfacial hypoplasia) create interface challenges 1
• Spend additional time choosing the right interface, preferring adjustable or custom-made masks 1
• CPAP therapy is feasible and effective, with 70% still using CPAP at 8 months and showing significant AHI reduction from 41.2 to 4.3 events/hour 1

Common Pitfalls and Solutions

Interface-Related Problems

The most frequent reason for CPAP/BiPAP intolerance or failure is interface issues 1:

• Pressure-related: skin damage, facial deformity 1
• Improper fitting: air leaks, mucosal drying, corneal ulcers 1
• Solution: Regular follow-up to assess mask fit, use nasal steroids or humidification for nasal obstruction 1

Complications to Monitor

• Eye irritation and conjunctivitis 1
• Skin ulceration 1
• Gastric distention 1
• Mask displacement leading to severe hypoxemia/hypercapnia in fragile patients 1
• Consider additional monitoring (pulse oximetry) since most bilevel machines lack built-in alarms 1

Treatment-Emergent Central Apneas

If central sleep apnea emerges during PAP titration (complex sleep apnea), consider adaptive servoventilation or down-titration of pressure. 1