What are the initial Expiratory Positive Airway Pressure (EPAP) and Inspiratory Positive Airway Pressure (IPAP) settings for tracheostomy patients requiring Bi-level Positive Airway Pressure (BiPAP) therapy?

Initial BiPAP Settings for Tracheostomy Patients

Start with IPAP of 8 cm H₂O and EPAP of 4 cm H₂O for tracheostomy patients, maintaining a minimum pressure differential of 4 cm H₂O between inspiratory and expiratory pressures. 1, 2

Starting Pressure Parameters

• Initial IPAP: 8 cm H₂O 1, 2
• Initial EPAP: 4 cm H₂O 1, 2
• Minimum pressure differential: 4 cm H₂O (must be maintained at all times) 1, 2
• Maximum pressure differential: 10 cm H₂O 1, 2

Maximum Pressure Limits

• Patients <12 years: Maximum IPAP of 20 cm H₂O 1, 2
• Patients ≥12 years: Maximum IPAP of 30 cm H₂O 1, 2

Ventilator Mode Selection

Use Spontaneous-Timed (ST) mode with backup rate for tracheostomy patients. 2, 3 This mode guarantees breath delivery even when patients cannot reliably trigger the ventilator, which is critical in tracheostomy patients who may have neuromuscular weakness or altered respiratory drive. 2

• Set backup rate equal to or slightly below the patient's spontaneous sleeping respiratory rate 2, 3
• Minimum backup rate: 10 breaths per minute 2, 3

Titration Protocol

Increase pressures by at least 1 cm H₂O increments with intervals no shorter than 5 minutes. 1, 2, 3

Specific Titration Rules:

• For obstructive apneas: Increase both IPAP and EPAP together 1, 2

  • Patients <12 years: Titrate after ≥1 apnea 1
  • Patients ≥12 years: Titrate after ≥2 apneas 1

• For hypopneas or flow limitations: Increase IPAP primarily 1, 2

  • Patients <12 years: Titrate after ≥1 hypopnea 1
  • Patients ≥12 years: Titrate after ≥3 hypopneas 1

• Continue titration until: Achieving at least 30 minutes without breathing events 1, 2

Critical Safety Considerations for Tracheostomy

BiPAP devices should NOT be used with tracheostomy if the patient requires reliable, life-sustaining ventilation. 2 BiPAP provides variable continuous flow via a blower with a fixed leak system designed to compensate for mask leaks, which can be problematic with tracheostomy tubes. 2 For patients requiring dependable ventilatory support, a true home mechanical ventilator is more appropriate than a BiPAP device. 1, 2

When BiPAP May Be Appropriate via Tracheostomy:

• Patients with neuromuscular disease who can tolerate brief periods off ventilation 4
• Patients transitioning from invasive mechanical ventilation who have improving respiratory drive 1, 4
• Patients with obstructive sleep apnea or obesity hypoventilation syndrome who have a tracheostomy for other reasons 1

Equipment Setup

• Humidification: Use heated humidification (26-29°C) connected to the tracheostomy with a swivel adapter 2
• Dead space: Minimize space between tracheostomy and exhalation valve to prevent CO₂ rebreathing 2
• Tube sizing: Ensure proper tracheostomy tube size, as undersized tubes increase work of breathing and require higher settings 2

Special Population Adjustments

Patients with elevated BMI or those undergoing retitration may benefit from higher starting pressures, though specific methodology lacks strong evidence. 1, 3 Consider starting IPAP at 10-12 cm H₂O and EPAP at 6-8 cm H₂O in obese patients with tracheostomy. 1

For obesity hypoventilation syndrome with tracheostomy, EPAP in the 10-15 cm H₂O range is often required to overcome upper airway obstruction and recruit collapsed lung units. 1 An inspiratory-to-expiratory (I:E) ratio of 1:1 may be needed to deliver adequate tidal volumes. 1

Monitoring Requirements

• Assess response within 1-2 hours of initiating BiPAP for acute respiratory distress 2
• Monitor for signs of inadequate ventilation: difficulty achieving gas exchange, plateau on end-tidal CO₂, or need for unexpectedly high settings 2
• Watch for treatment-emergent central apneas; if present, decrease IPAP or ensure ST mode with backup rate is active 1

Common Pitfalls

• Using BiPAP for life-sustaining ventilation: BiPAP devices are not designed for patients who cannot tolerate any interruption in ventilatory support 2
• Inadequate humidification: Tracheostomy bypasses upper airway humidification; heated humidification is essential 2
• Excessive dead space: Can lead to CO₂ retention and inadequate ventilation 2
• Ignoring backup rate: Tracheostomy patients often have impaired respiratory drive and require guaranteed breath delivery 2, 3