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 pressure differential of 4 cm H₂O between inspiratory and expiratory pressures. 1
Standard Initial Settings
- IPAP (Inspiratory Positive Airway Pressure): 8 cm H₂O 1
- EPAP (Expiratory Positive Airway Pressure): 4 cm H₂O 1
- Minimum pressure support (IPAP-EPAP differential): 4 cm H₂O 1
- Maximum pressure support differential: 10 cm H₂O 1
These settings apply universally to both pediatric and adult patients according to the American Academy of Sleep Medicine guidelines. 1
Maximum Pressure Limits
- For patients <12 years: Maximum IPAP of 20 cm H₂O 1
- For patients ≥12 years: Maximum IPAP of 30 cm H₂O 1
When to Modify Initial Settings
For patients with elevated BMI or those undergoing retitration, start with higher initial pressures than the standard 8/4 cm H₂O settings. 1 While specific pressure values are not defined by guidelines, clinical judgment should guide upward adjustment based on body habitus. 1
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
Specific adjustment criteria:
- For obstructive apneas: Increase both IPAP and EPAP if ≥2 apneas occur in patients ≥12 years (or ≥1 apnea in patients <12 years) 1
- For hypopneas: Increase IPAP if ≥3 hypopneas occur in patients ≥12 years 1
- For RERAs: Increase IPAP if ≥5 RERAs occur in patients ≥12 years 1
- For snoring: Increase IPAP and/or EPAP as needed 1
Continue upward titration until achieving at least 30 minutes without breathing events. 1
Mode Selection
Use spontaneous mode (S mode) for obstructive sleep apnea where the patient triggers all breaths. 2
Switch to spontaneous-timed mode (ST mode) with backup rate if the patient demonstrates:
- Frequent and significant central apneas at baseline or during titration 3
- Inappropriately low respiratory rate 3
- Failure to reliably trigger IPAP/EPAP transitions due to muscle weakness 3
When using ST mode, set the backup respiratory rate equal to or slightly less than the patient's spontaneous sleeping respiratory rate, with a minimum of 10 breaths per minute. 4, 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
Patient discomfort with high pressures is a valid clinical indication for BiPAP even before reaching the 15 cm H₂O threshold. 2
Common Pitfalls and How to Avoid Them
If the patient awakens and complains that the 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, as this leads to poor adherence. 2
Monitor for treatment-emergent central apneas during titration. 1 If they develop, consider decreasing IPAP or adjusting to ST mode with backup rate. 1
Ensure all patients receive adequate BiPAP education, hands-on demonstration, careful mask fitting, and acclimatization prior to titration. 1, 2 Proper mask fitting is essential to minimize leaks that reduce treatment effectiveness. 2
Special Considerations for Acute Care Settings
For patients with acute respiratory failure or aspiration, evaluate response within 1-2 hours of initiating BiPAP. 4, 2 This narrow window is essential because delayed intubation due to failed noninvasive ventilation can cause harm. 4
Inability to maintain SpO₂ >90% despite FiO₂ escalation indicates BiPAP failure requiring intubation. 4, 2