Initial BiPAP Settings
For adult and pediatric patients requiring BiPAP, start with IPAP of 8 cm H₂O and EPAP of 4 cm H₂O, maintaining a minimum pressure differential of 4 cm H₂O between inspiratory and expiratory pressures. 1
Starting Parameters
Pressure Settings
- IPAP (Inspiratory Positive Airway Pressure): 8 cm H₂O 1
- EPAP (Expiratory Positive Airway Pressure): 4 cm H₂O 1
- Minimum IPAP-EPAP differential: 4 cm H₂O 1
- Maximum IPAP-EPAP differential: 10 cm H₂O 1
Maximum Pressure Limits
Special Considerations for Starting Pressures
Patients with elevated BMI or those undergoing retitration may benefit from higher starting IPAP or EPAP, though specific methodology for determining these pressures a priori lacks strong evidence. 1
Titration Algorithm
Pressure Adjustment Intervals
Increase IPAP and/or EPAP by at least 1 cm H₂O increments with intervals no shorter than 5 minutes to eliminate obstructive respiratory events. 1
Event-Specific Titration Triggers
For Obstructive Apneas:
- Increase both IPAP and EPAP if ≥1 apnea in patients <12 years 1
- Increase both IPAP and EPAP if ≥2 apneas in patients ≥12 years 1
For Hypopneas:
- Increase IPAP if ≥1 hypopnea in patients <12 years 1
- Increase IPAP if ≥3 hypopneas in patients ≥12 years 1
For RERAs (Respiratory Effort-Related Arousals):
For Snoring:
- May increase IPAP if ≥1 minute of loud/unambiguous snoring in patients <12 years 1
- May increase IPAP if ≥3 minutes of loud/unambiguous snoring in patients ≥12 years 1
Titration Goals
Continue upward titration until achieving at least 30 minutes without breathing events, ideally including at least 15 minutes in supine REM sleep. 1
Mode Selection for Chronic Alveolar Hypoventilation
When to Use ST (Spontaneous-Timed) Mode
Use ST mode with backup rate if the patient demonstrates:
- Frequent and significant central apneas at baseline or during titration 1
- Inappropriately low respiratory rate 1
- Failure to reliably trigger IPAP/EPAP transitions due to muscle weakness 1
- Treatment-emergent central apneas during BiPAP titration 1
Backup Rate Settings
Set the initial backup rate equal to or slightly less than the patient's spontaneous sleeping respiratory rate (minimum 10 breaths per minute). If sleeping respiratory rate is unknown, use the awake spontaneous respiratory rate. 1
Inspiratory Time Settings
Set initial inspiratory time (IPAP time) to achieve a %IPAP time between 30-40% of the cycle time. 1
- For obstructive airways disease: Use shorter inspiratory time (~30% IPAP time) to allow adequate exhalation time 1
- For restrictive disease: Use longer inspiratory time (~40% IPAP time) to accommodate decreased respiratory system compliance 1
- Default inspiratory time: 1.2 seconds is commonly used 1
Common Pitfalls and Management
Patient Intolerance
If the patient awakens complaining pressure is too high, restart at a lower pressure that the patient reports is comfortable enough to allow return to sleep, then resume gradual titration. 1
Treatment-Emergent Central Apneas
If central apneas develop during titration, decrease IPAP or switch to ST mode with backup rate to address complex sleep apnea. 1
Pressure Exploration
After achieving control of respiratory abnormalities, "exploration" of IPAP above the control pressure should not exceed 5 cm H₂O to optimize upper airway resistance without excessive pressure. 1
COPD Patients
Exercise caution with BiPAP in spontaneously breathing COPD patients, as research demonstrates BiPAP can increase work of breathing and respiratory muscle effort compared to pressure support ventilation. 2 In these patients, pressure support may be superior for reducing respiratory muscle effort. 2
Clinical Context Considerations
BiPAP is indicated when patients are uncomfortable or intolerant of high CPAP pressures, or when obstructive events persist at CPAP of 15 cm H₂O. 1