Is BiPAP (Bilevel Positive Airway Pressure) okay for patients with a Do Not Intubate (DNI) order?

BiPAP Use in DNI Patients

Yes, BiPAP is appropriate and often the preferred intervention for patients with a Do Not Intubate (DNI) order who develop acute respiratory failure, provided they meet specific clinical criteria and do not have absolute contraindications. 1

Core Rationale for BiPAP in DNI Patients

BiPAP serves as the primary respiratory support modality when invasive mechanical ventilation is not an option due to patient preferences or goals of care. The key distinction is that BiPAP can be used in DNI patients even when some relative contraindications exist, as long as contingency plans acknowledge that intubation will not occur if BiPAP fails. 2

The European Respiratory Society explicitly states that contraindications to NIV (including confusion/agitation, copious secretions, or severe co-morbidity) can be overridden when "a decision has been made not to proceed to invasive ventilation." 2 This directly addresses the DNI scenario.

Clinical Conditions Where BiPAP Benefits DNI Patients

Strong Indications:

• COPD exacerbations with respiratory acidosis (pH <7.35): BiPAP reduces intubation rates and mortality in hypercapnic respiratory failure, making it ideal for DNI patients. 1, 3
• Cardiogenic pulmonary edema: Both BiPAP and CPAP decrease mortality (RR 0.80) and intubation rates (RR 0.60), with BiPAP reserved for cases where CPAP fails or respiratory acidosis develops. 1
• Neuromuscular disease with acute-on-chronic respiratory failure: BiPAP is specifically indicated for chest wall deformity or neuromuscular conditions causing hypercapnic failure. 2, 1

Conditional Use:

• Post-operative respiratory failure: NIV reduces mortality (RR 0.28) and intubation rates (RR 0.27) after thoracic or abdominal surgery. 1
• Hypoxemic respiratory failure: Only in highly selected, cooperative patients managed by experienced teams in ICU settings, as evidence shows reduced intubation rates but no mortality benefit. 1

Absolute Contraindications That Apply Even in DNI Patients

BiPAP should not be used in DNI patients with: 1, 3

• Recent facial or upper airway surgery
• Facial burns or trauma
• Fixed upper airway obstruction
• Active vomiting
• Inability to protect the airway
• Life-threatening hypoxemia unresponsive to high FiO2
• Apnea or impending respiratory arrest 3

Special DNI Considerations

Active Bleeding Scenarios:

• Massive hemoptysis: BiPAP should be discontinued during active bleeding (consensus rating 8/10). 2
• Pneumothorax: BiPAP should be discontinued until chest tube placement in most cases, though it can be used cautiously with a drain in place. 2

Modified Monitoring Approach:

Since intubation is not an option, the monitoring strategy shifts from "prepare for intubation if failing" to "optimize comfort and respiratory support within BiPAP capabilities":

• Initial assessment at 1-2 hours: Check arterial blood gases for pH, PaCO2, and PaO2. 4, 1
• Continuous SpO2 monitoring: Target 88-94% (or 90-96% depending on condition). 4, 3
• Clinical indicators of BiPAP failure in DNI context: Worsening mental status, hemodynamic instability, progressive hypercapnia with pH <7.25, or patient exhaustion signal need for comfort-focused care transition rather than intubation. 4, 3

Practical Implementation Algorithm for DNI Patients

1. Confirm DNI status and ensure goals of care discussion has occurred with patient/family
2. Screen for absolute contraindications listed above 1
3. Initiate BiPAP with starting pressures: IPAP 8-14 cmH2O, EPAP 4-8 cmH2O 1, 3
4. Titrate pressures to IPAP 14-20 cmH2O and EPAP 4-8 cmH2O as tolerated 3
5. Reassess at 1-2 hours: If improving (better pH, lower PaCO2, reduced work of breathing), continue BiPAP 4
6. If failing at 1-2 hours: Optimize settings, address mask fit, manage secretions, but recognize that transition to comfort measures may be appropriate rather than escalation 4, 3

Critical Pitfall to Avoid

Do not delay recognition of BiPAP failure beyond 1-2 hours in DNI patients. 4 While intubation is not an option, prolonged ineffective BiPAP causes unnecessary suffering. The British Thoracic Society emphasizes that delayed decision-making increases mortality, and in the DNI context, this translates to prolonged distress. 4 When BiPAP clearly fails, transition to comfort-focused care with opioids and anxiolytics is appropriate. 4

Location of Care

DNI patients on BiPAP with persistent dyspnea, hemodynamic instability, or pH <7.25 should still be managed in ICU/HDU settings for optimal monitoring and symptom management, even though intubation is not planned. 4