Can BiPAP (Bilevel Positive Airway Pressure) cause pneumothorax in patients with large pleural effusions, particularly those with underlying conditions such as heart failure, kidney disease, or cancer?

BiPAP and Pneumothorax Risk in Pleural Effusion Patients

I cannot provide you with a case report or article demonstrating that BiPAP causes pneumothorax specifically in patients with large pleural effusions, because the available evidence does not establish this causal relationship.

What the Evidence Actually Shows

BiPAP and Existing Pneumothorax

The guidelines address BiPAP use when pneumothorax is already present, not whether BiPAP causes pneumothorax:

• BiPAP should be discontinued in patients who have developed a pneumothorax (regardless of size) because positive pressure ventilation may worsen or enlarge an existing pneumothorax 1.
• The American Journal of Respiratory and Critical Care Medicine guidelines recommend withholding BiPAP "for fear that it may cause progression of the complication" in patients with established pneumothorax 1.
• The median consensus score was 8 (IQR 5-9) for small pneumothorax and 8 (IQR 6-9) for large pneumothorax regarding BiPAP discontinuation 1, 2.

BiPAP Use in Pleural Effusion

The research evidence shows BiPAP can be used safely in pleural effusion:

• One study successfully used BiPAP in a patient with malignant pleural effusion without complications, with the patient classified as a responder to BiPAP ventilation 3.
• BiPAP was found "simple, safe, effective and well tolerated" in patients with respiratory distress from various causes including pleural effusion 3.

Critical Distinction

The concern with BiPAP is progression of existing pneumothorax, not causation of new pneumothorax in pleural effusion patients 1, 2. The guidelines discuss BiPAP discontinuation in the context of hemoptysis and established pneumothorax in cystic fibrosis patients, not as a risk factor for developing pneumothorax in pleural effusion 1.

Clinical Caveat

While positive pressure ventilation theoretically could contribute to barotrauma in any patient with compromised lung parenchyma, no evidence in the provided literature documents BiPAP causing pneumothorax specifically in large pleural effusion patients 1, 2, 3.