What are the initial BiPap (Bilevel Positive Airway Pressure) settings for a tracheostomy patient?

BiPAP Settings for Tracheostomy Patients

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, 2, 3

Initial Pressure Settings

• Begin with IPAP 8 cm H₂O and EPAP 4 cm H₂O as the standard starting point for both adult and pediatric tracheostomy patients 1, 2, 3
• Maintain a minimum IPAP-EPAP differential of 4 cm H₂O at all times 1, 2, 3
• The maximum pressure differential should not exceed 10 cm H₂O 1, 2, 3
• For patients with elevated BMI or those requiring retitration, consider starting with higher initial pressures than these standard values 1, 2

Maximum Pressure Limits

• For patients under 12 years: Maximum IPAP of 20 cm H₂O 1, 2, 3
• For patients 12 years and older: Maximum IPAP of 30 cm H₂O 1, 2, 3

Mode Selection for Tracheostomy

• Use Spontaneous-Timed (ST) mode with backup rate for tracheostomy patients, as this guarantees breath delivery even if the patient cannot reliably trigger the ventilator 1, 3
• Set the initial backup rate equal to or slightly less than the patient's spontaneous sleeping respiratory rate, with a minimum of 10 breaths per minute 3
• ST mode is particularly important for patients with poor respiratory drive, muscle weakness, or those who demonstrate frequent central apneas 3

Titration Algorithm

• Increase IPAP and/or EPAP by at least 1 cm H₂O increments with intervals no shorter than 5 minutes 1, 3
• Continue upward titration until achieving at least 30 minutes without breathing events 3
• For obstructive apneas: increase both IPAP and EPAP 1, 3
• For hypopneas or flow limitations: increase IPAP primarily 1, 3

Critical Caveats for Tracheostomy Patients

BiPAP ventilators are NOT designed for life support and should be used with extreme caution in tracheostomy-dependent patients. 1 The American Thoracic Society explicitly states that bilevel positive airway pressure ventilation should not be used with a tracheostomy if the patient requires reliable, life-sustaining ventilation 1. If a child has a tracheostomy and requires dependable ventilation, positive pressure ventilation using a conventional ventilator is much more reliable and effective than using BiPAP 1.

• BiPAP devices provide variable continuous flow via a blower with a fixed leak system, which can compensate for leaks around masks but may be problematic with tracheostomy tubes 1
• These devices are smaller, less expensive, and easier to use than conventional ventilators, but lack the reliability needed for patients requiring continuous ventilatory support 1
• Research demonstrates that tracheostomy tubes themselves impose additional work of breathing (0.382-0.908 J/L depending on minute ventilation), which may not be adequately compensated by BiPAP 4

When BiPAP May Be Appropriate for Tracheostomy

BiPAP through tracheostomy may be considered in highly selected cases:

• Patients with ALS requiring long-term home mechanical ventilation have been successfully managed with BiPAP through tracheostomy using modified connections, with mean duration of 39 months 5
• Older children (>6-8 years) with milder phenotypes who are transitioning from conventional ventilators may tolerate BiPAP 1
• Patients must be hemodynamically stable, cooperative, and not requiring continuous life support 6

Equipment Considerations

• Use heated humidification (temperature range 26-29°C) connected to the tracheostomy with a swivel adapter 1
• Minimize dead space between the tracheostomy and exhalation valve to avoid elevated CO₂ due to rebreathing 1
• Ensure proper tracheostomy tube sizing, as undersized tubes increase work of breathing and may require higher ventilator settings 1

Monitoring Requirements

• Evaluate blood gas analysis before discharge and regularly during follow-up to ensure adequate ventilation 5
• Monitor for signs of inadequate ventilation including difficulty achieving adequate gas exchange, visible plateau on end-tidal CO₂ monitoring, or need to increase settings above expected levels 1
• For acute respiratory distress, assess response within 1-2 hours of initiating BiPAP 2