What are the initial BiPAP (Bilevel Positive Airway Pressure) settings?

Initial BiPAP Settings

Start with IPAP of 8 cm H₂O and EPAP of 4 cm H₂O for all adult and pediatric patients, maintaining a minimum 4 cm H₂O pressure differential between inspiratory and expiratory pressures. 1, 2, 3

Standard Starting Parameters

• IPAP (Inspiratory Positive Airway Pressure): Begin at 8 cm H₂O 1, 2, 3
• EPAP (Expiratory Positive Airway Pressure): Begin at 4 cm H₂O 1, 2, 3
• Pressure Differential: Maintain minimum 4 cm H₂O between IPAP and EPAP at all times 2, 3
• Maximum Differential: Do not exceed 10 cm H₂O between IPAP and EPAP 1, 2, 3

Maximum Pressure Limits

• Patients <12 years: Maximum IPAP of 20 cm H₂O 1, 2, 3
• Patients ≥12 years: Maximum IPAP of 30 cm H₂O 1, 2, 3

Titration Algorithm

Increase IPAP and/or EPAP by at least 1 cm H₂O increments with intervals no shorter than 5 minutes until obstructive respiratory events are eliminated. 1, 2, 3

Event-Specific Titration Rules:

• Obstructive Apneas: Increase both IPAP and EPAP if ≥1 apnea in patients <12 years OR ≥2 apneas in patients ≥12 years 1, 3
• Hypopneas: Increase IPAP if ≥1 hypopnea in patients <12 years OR ≥3 hypopneas in patients ≥12 years 3
• RERAs (Respiratory Effort-Related Arousals): Increase IPAP if ≥3 RERAs in patients <12 years OR ≥5 RERAs in patients ≥12 years 3
• Snoring: Increase IPAP and/or EPAP until eliminated 1

Titration Goal:

• Continue upward titration until achieving at least 30 minutes without breathing events, ideally including at least 15 minutes in supine REM sleep 3

When to Switch from CPAP to BiPAP

Switch to BiPAP when the patient is uncomfortable or intolerant of high CPAP pressures, or when obstructive respiratory events persist at 15 cm H₂O of CPAP. 1, 2, 3

• Patient discomfort with high pressures is a valid indication for BiPAP even before reaching the 15 cm H₂O threshold 2

Special Population Adjustments

Elevated BMI Patients:

• Consider starting with higher initial IPAP or EPAP than standard 8/4 cm H₂O, though exact pressures should be determined by body habitus 1, 2, 3

Retitration Studies:

• Higher starting pressures may be selected based on previous titration results 1, 3

Mode Selection

• Spontaneous Mode (S mode): Use for obstructive sleep apnea where patient triggers all breaths 2
• Spontaneous-Timed Mode (ST mode): Use with backup rate if patient demonstrates frequent central apneas, inappropriately low respiratory rate, or failure to reliably trigger IPAP/EPAP transitions due to muscle weakness 3
• Backup Rate: Set equal to or slightly less than the patient's spontaneous sleeping respiratory rate (minimum 10 breaths per minute) 3

Critical Pitfalls to Avoid

• If patient awakens complaining pressure is too high: Restart at a lower pressure that the patient reports is comfortable enough to allow return to sleep 1, 2
• Do not persist with uncomfortable pressures: This leads to poor adherence and treatment failure 2
• Ensure proper mask fitting: Poor mask fit causes leaks that reduce treatment effectiveness 2

Pre-Titration Requirements

All patients must receive adequate BiPAP education, hands-on demonstration, careful mask fitting, and acclimatization prior to titration. 1, 2

Acute Care Settings (Emergency Department/ICU)

• Initial Settings: Start at 8/3 cm H₂O and gradually raise to 12/7 cm H₂O IPAP/EPAP 4
• Response Evaluation: Assess within 1-2 hours of initiating BiPAP 2
• Failure Criteria: Inability to maintain SpO₂ >90% despite FiO₂ escalation indicates BiPAP failure requiring intubation 2

Pediatric Asthma-Specific Settings

• Median Effective Settings: IPAP 18 cm H₂O (range 12-28), EPAP 8 cm H₂O (range 6-10) 5
• I:E Ratio: 1.75 (range 1.5-1.75) for optimal air trapping reduction 5
• Higher IPAP with lower EPAP and longer I:E ratio optimizes settings in severe pediatric asthmatics 5