When is BiPAP (Bilevel Positive Airway Pressure) contraindicated in patients with conditions such as hypotension, acute heart failure, severe respiratory acidosis, or dementia?

When BiPAP Should Not Be Used

BiPAP must be withheld in patients with pneumothorax, should be stopped during massive hemoptysis, and requires extreme caution in hypotensive patients due to its blood pressure-lowering effects. 1

Absolute Contraindications

Active Pneumothorax

• BiPAP should be withheld from patients with pneumothorax as long as the pneumothorax is present, regardless of size. 1
• Positive pressure ventilation can cause progression of pneumothorax, even in patients with severe obstructive airways disease who may depend on BiPAP support. 1
• If the patient requires ventilatory support during pneumothorax, observation in the intensive care unit may be appropriate while BiPAP is withheld. 1

Massive Hemoptysis

• BiPAP should be withheld from patients with massive hemoptysis. 1
• The positive pressure can disrupt clot formation and worsen bleeding in patients with significant hemoptysis. 1
• For scant hemoptysis, BiPAP should not be withheld, as the risks do not outweigh benefits. 1

Severe Hypotension and Hemodynamic Instability

• BiPAP reduces blood pressure and should be used with extreme caution in hypotensive patients. 1, 2
• Blood pressure must be monitored regularly when BiPAP is used, as positive pressure further reduces blood pressure regardless of volume status. 1, 2
• Do not use BiPAP in patients with severe hemodynamic instability or cardiogenic shock. 3

Imminent Respiratory Arrest

• Proceed immediately to endotracheal intubation rather than BiPAP if the patient has apnea or impending respiratory arrest. 4, 3
• Severe respiratory distress unresponsive to initial BiPAP or depressed consciousness requires immediate intubation. 4

Inability to Protect Airway or Maintain Mask Seal

• Facial trauma preventing adequate mask seal is an absolute contraindication. 4, 3
• Patients unable to protect their airway should not receive BiPAP. 3

Relative Contraindications and High-Risk Scenarios

Recent Myocardial Infarction

• Recent myocardial infarction represents a relative contraindication for BiPAP. 2
• Some evidence suggests BiPAP may be associated with higher MI rates compared to CPAP in acute cardiogenic pulmonary edema, though this remains controversial. 2, 4, 3, 5
• In acute heart failure with pulmonary edema, CPAP should be preferred initially over BiPAP unless hypercapnia, coexisting COPD, or respiratory muscle fatigue is present. 4, 3

Severe Acidosis Despite Treatment

• Persisting pH <7.15 or deteriorating pH despite optimized BiPAP settings indicates failure and need for intubation. 4
• If there is no improvement or worsening after 1-2 hours of optimized BiPAP, or persistent/worsening hypercapnia with pH <7.25, proceed immediately to endotracheal intubation. 3

Critical Monitoring Requirements When BiPAP Is Used

When BiPAP is deemed appropriate despite risks, continuous monitoring is essential:

• Monitor arterial oxygen saturation, blood pressure, respiratory rate, heart rate, and mental status continuously. 2, 3
• Check arterial or venous blood gas (pH, PaCO2) within 2-4 hours of initiation. 4
• Be prepared for immediate intubation if the patient deteriorates. 4, 3

Common Pitfalls to Avoid

• Do not delay definitive airway management (intubation) by attempting BiPAP in patients with severe hemodynamic instability or depressed consciousness. 4, 3
• Do not continue BiPAP in the presence of pneumothorax, even if the patient has severe underlying lung disease. 1
• Do not rely on IVC indices for volume status assessment in BiPAP patients with IPAP >15 cmH2O or EPAP >8 cmH2O, as positive pressure fundamentally reverses normal physiology. 2