What is the management for a patient desaturating despite being on Bi-level Positive Airway Pressure (BiPAP) with Fraction of Inspired Oxygen (FiO2) 100%?

Management of Patient Desaturating Despite BiPAP with FiO2 100%

Proceed immediately to endotracheal intubation without delay, as continued desaturation on maximal noninvasive support indicates BiPAP failure and delayed intubation is associated with increased mortality. 1, 2

Immediate Recognition of BiPAP Failure

Your patient meets clear criteria for BiPAP failure and requires immediate intubation:

• Persistent or worsening hypoxemia despite FiO2 100% is an absolute indication for intubation 1, 2
• The World Health Organization states that patients on BiPAP should be supervised by experienced clinicians capable of performing endotracheal intubation if the patient fails to improve or rapidly deteriorates 3, 1
• Do not wait beyond 1-2 hours if there is no improvement in arterial blood gases (pH and PaCO2) on optimal BiPAP settings 1, 2
• Additional signs of failure include deteriorating conscious level, hemodynamic instability, or patient intolerance of the device 1, 2

Pre-Intubation Optimization

Continue BiPAP with 100% FiO2 until the moment of intubation to maximize preoxygenation and prolong safe apnea time 3, 1:

• The Society of Critical Care Medicine recommends preoxygenation with NIPPV in patients with severe hypoxemia (PaO2/FiO2 <150) as it has the strongest evidence for decreasing critical desaturation during intubation 3
• Position the patient in semi-Fowler position (head elevated 20-30°) during intubation to improve first-pass success and prolong time to desaturation 3, 1
• Have an experienced clinician perform the intubation using rapid sequence intubation with a neuromuscular blocking agent (rocuronium or succinylcholine) when using a sedative-hypnotic 1

Immediate Post-Intubation Ventilator Settings

Implement lung-protective ventilation immediately to minimize ventilator-induced lung injury 1, 2:

• Tidal volume: 6 mL/kg predicted body weight (may increase to 8 mL/kg if not tolerated, but never exceed this) 3, 1, 2
• Target plateau pressure <30 cmH2O, ideally <28 cmH2O 3, 1, 2
• Titrate PEEP guided by FiO2 requirements using the ARDSnet protocol to achieve SpO2 >90% 3, 1, 2
• Allow permissive hypercapnia with PaCO2 permitted to rise while maintaining arterial pH >7.20 3, 1, 2
• Start with FiO2 100% and titrate down to maintain SpO2 92-97%, avoiding prolonged hyperoxia (PaO2 >300 mmHg) which is associated with increased mortality 1

Advanced Interventions if No Improvement After 12 Hours

Consider early prone positioning if PaO2/FiO2 <150 despite ventilator optimization 3, 1, 2:

• Prone ventilation improves oxygenation in approximately 65% of ARDS patients 1, 2
• Duration should be 12-16 hours daily 3, 1, 2
• Early airway pressure release ventilation should be considered in certain patients 3

Consider ECMO for refractory hypoxemia despite lung-protective ventilation if extracorporeal life support is available 3, 1, 2

Critical Pitfalls to Avoid

• Never delay intubation in a patient failing BiPAP with maximal support, as this significantly increases mortality 3, 1, 2
• Never use tidal volumes >8 mL/kg predicted body weight even if hypercapnia develops, as this increases mortality 1, 2
• Do not attempt to normalize blood gases at the expense of lung-protective ventilation parameters 2
• Avoid using noninvasive ventilation in sepsis-related ARDS patients, as they are more likely to fail this therapy and delay in intubation may result in complications 3

Special Considerations

If the patient is morbidly obese, recognize that higher BiPAP pressures may have been needed (EPAP 10-15 cmH2O, IPAP >30) due to upper airway obstruction and high impedance to inflation, and these patients have greater risk of difficult intubation 2

After intubation, if ventilation remains difficult despite correct tube placement, systematically rule out equipment failure, blocked endotracheal tube, bronchospasm, anaphylaxis, or pneumothorax 4