1. BiPAP
Steven Podnos MD

3. Non Invasive Ventilation
• Using positive pressure ventilation without an
endotracheal tube
• Used for Obstructive Sleep Apnea, Respiratory
Support of various illnesses to prevent
intubation

4. CPAP
• Continuous Positive Airway Pressure-usually a
set level pressure-same with inspiration and
expiration. Note that Expiratory Pressure is
the same thing as PEEP (Positive End
Expiratory Pressure). Normal PEEP is zero!

5. BiPAP vs. CPAP
• Individually set Inspiratory and Expiratory
Pressures.
• Indicated for difficulty with Oxygenation
(EPAP/PEEP) and/or Respiratory muscle
support (IPAP)
• Contraindications: Risk of
Aspiration, Agitation, Poor cough

6. Indications
• Suitable clinical conditions for noninvasive ventilation (most patients)
Chronic obstructive pulmonary disease
• Cardiogenic pulmonary edema
• Suitable clinical conditions for noninvasive ventilation (selected patients)
After discontinuation of mechanical ventilation (COPD)
• Community-acquired pneumonia (and COPD)
• Asthma
• Immunocompromised state
• Postoperative respiratory distress and respiratory failure
• Do-not-intubate status
• Neuromuscular respiratory failure
• Decompensated obstructive sleep apnea/cor pulmonale
• Cystic fibrosis
• Acute respiratory distress syndrome

7. Advantages of BiPAP
• May reverse impending respiratory failure and
avoid intubation
• Reduced risk of nosocomial pneumonia
• Buys time while reversing hypercapnia and
cardiogenic pulmonary edeama

8. Disadvantages of BiPAP
• Complications of noninvasive ventilation
• Facial and nasal pressure injury and sores
– Result of tight mask seals used to attain adequate inspiratory volumes
– Minimize pressure by intermittent application of noninvasive ventilation
– Schedule breaks (30-90 min) to minimize effects of mask pressure
– Balance strap tension to minimize mask leaks without excessive mask pressures
– Cover vulnerable areas (erythematous points of contact) with protective dressings
• Gastric distension
– Rarely a problem
– Avoid by limiting peak inspiratory pressures to less than 25 cm water
– Nasogastric tubes can be placed but can worsen leaks from the mask
– Nasogastric tube also bypasses the lower esophageal sphincter and permits reflux
• Dry mucous membranes and thick secretions
– Seen in patients with extended use of noninvasive ventilation
– Provide humidification for noninvasive ventilation devices
– Provide daily oral care
• Aspiration of gastric contents
– Especially if emesis during noninvasive ventilation
– Avoid noninvasive ventilation in patient with ongoing emesis or hematemesis
• Complications of both noninvasive and invasive ventilation
Barotrauma (significantly less risk with noninvasive ventilation)
• Hypotension related to positive intrathoracic pressure (support with fluids)

9. BiPAP Settings
• Typically begin with 10cm Inspiratory and 5cm
Expiratory Pressures. Adjust as needed for
support and hypoxemia.
• Remember, EPAP = PEEP
• PEEP paradoxically can help with both Shunt
and Obstructive Disease

10. Use in COPD

11. Monitoring BiPAP
• Look at Patient-HR, RR, BP
• Increasing pCO2 a bad sign
• Worsening Hypoxemia a bad sign

12. Weaning BiPAP
• May slowly reduce both inspiratory and
expiratory pressures
• May alternatively just switch to simple
supplemental Oxygen

13. High Flow Nasal Cannula
• In infants, high flow Nasal Cannula appears to have
some positive pressure benefit and may be equivalent
to Nasal CPAP in efficacy
• In Adults, allows higher concentration of inspired
oxygen than a traditional nasal cannula. Flows at
35L/min appear to provide low levels of positive
pressure (CPAP), especially with a closed mouth.

14. HFNC

15. HFNC or BiPAP in Adults
• If the patient requires positive pressure
ventilation, choose BiPAP.
• If they patient primarily requires a high level
of inspired oxygen (CHF, ARDS without
fatigue), then HFNC may be adequate