What are the contraindications for BiPAP (Bilevel Positive Airway Pressure) therapy in patients?

Contraindications for BiPAP Therapy

BiPAP should never be used in patients with apnea/impending respiratory arrest, inability to protect the airway, active vomiting, facial trauma/burns, fixed upper airway obstruction, or life-threatening hypoxemia unresponsive to high FiO2—these are absolute contraindications requiring immediate intubation instead. 1

Absolute Contraindications (Never Use BiPAP)

• Apnea or impending respiratory arrest - the patient requires immediate intubation 1
• Inability to protect the airway - risk of aspiration makes BiPAP dangerous 1
• Active vomiting - high aspiration risk with positive pressure 1
• Recent facial or upper airway surgery - disrupts surgical sites and healing 2
• Facial burns or trauma - prevents adequate mask seal and causes tissue damage 1, 2
• Fixed upper airway obstruction - positive pressure cannot overcome mechanical blockage 2
• Life-threatening hypoxemia unresponsive to high FiO2 - BiPAP will not correct this; intubation needed 2

Relative Contraindications (Use With Extreme Caution or Avoid)

Cardiovascular Contraindications

• Recent myocardial infarction - BiPAP may be associated with higher MI rates compared to CPAP in acute heart failure, though it can be used cautiously in selected cases 1, 3
• Severe hypotension - positive pressure further reduces blood pressure regardless of volume status 3
• Hemodynamic instability - requires ICU monitoring if BiPAP attempted 2

Pulmonary Contraindications

• Pneumothorax - BiPAP must be discontinued until chest tube placement; can be used cautiously only after drain is in place 1, 2
• Massive hemoptysis - BiPAP should be discontinued during active bleeding 1, 2

Neurological/Cooperation Issues

• Inability to cooperate or follow commands - patient cannot maintain mask or signal distress 1
• Severe agitation or altered mental status - prevents safe mask use 1
• Inability to manage secretions - risk of aspiration with positive pressure 1

Special Disease Considerations

• Acute Guillain-Barré syndrome with deteriorating respiratory function - BiPAP has failed catastrophically in case reports, with patients requiring emergency intubation after initial improvement; strongly avoid in progressing GBS 4
• Obesity hypoventilation syndrome (OHS) - not a contraindication but requires liberal use of BiPAP with close monitoring due to higher risk of respiratory adverse events 5

Clinical Decision Algorithm

When BiPAP fails or is contraindicated:

1. Proceed to intubation immediately if:

   • No improvement or worsening after 1-2 hours of BiPAP trial 1
   • Persistent or worsening hypercapnia with pH <7.25 1
   • Worsening mental status or inability to cooperate 1
   • Hemodynamic deterioration 1
   • Patient exhaustion despite BiPAP support 1

2. In DNI (Do Not Intubate) patients: Absolute contraindications still apply, but relative contraindications can be overridden when invasive ventilation is not an option, with transition to comfort-focused care (opioids and anxiolytics) when BiPAP clearly fails 2

Common Pitfalls to Avoid

• Poor mask fit leads to air leaks and treatment failure—mask selection is critical for success 1
• Excessive pressure settings (IPAP >20 cmH2O or EPAP >8 cmH2O) can cause gastric distension or paradoxically increase work of breathing 1, 3
• Using BiPAP in deteriorating GBS patients based on success in other neuromuscular diseases—this has resulted in acute cyanosis and emergency intubations 4
• Relying on IVC indices for volume assessment in BiPAP patients with IPAP >15 cmH2O or EPAP >8 cmH2O—positive pressure reverses normal physiology and makes these measurements unreliable 3