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Uploaded byChaithanya Malalur
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Bpap (bi level positive airway pressure)

1. Bilevel positive airway pressure (BPAP) delivers two levels of positive airway pressure - a higher pressure during inspiration and a lower pressure during expiration - to reduce work of breathing and improve oxygenation. 2. BPAP is effective for acute exacerbations of COPD and cardiogenic pulmonary edema by reducing mortality, need for intubation, and treatment failure compared to standard care. 3. For pneumonia, outcomes are worse with post-obstructive pneumonia, pleural effusions, hypoxic hypercapnic respiratory failure with effusions, and over 24 hours on BPAP therapy.

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BPAPBilevel positive airway pressure
Contents ▪ Introduction ▪ Uses and contraindications ▪ BPAP settings and monitoring ▪ Clinical studies ▪ Summary and take home message
Noninvasive ventilation ▪ Noninvasive ventilation (NIV) refers to positive pressure ventilation delivered through a noninvasive interface (nasal mask, facemask, or nasal plugs), rather than an invasive interface (endotracheal tube, tracheostomy) that delivers continuous positive airway pressure (CPAP) or bilevel positive airway support (BPAP) ▪ Its use has become more common as its benefits are increasingly recognized 3
NIV ▪ NIV reduces patient work of breathing and improve respiratory gas exchange ▪ while avoiding the risks and complications:  related to the placement of an endotracheal tube  administration of sedation and neuromuscular blockade  delivery of invasive mechanical ventilation. 4
Conditions known to respond to NIV 1. Exacerbations of chronic obstructive pulmonary disease (COPD) that are complicated by hypercapnic acidosis (arterial carbon dioxide tension [PaCO ] >45 mmHg or pH <7.30) 2. Cardiogenic pulmonary edema 3. Acute hypoxemic respiratory failure 4. NIV may also be helpful for preventing post- extubation respiratory failure 5
NAV use ▪ Despite evidence of efficacy, NIV may be underutilized among patients with cardiogenic pulmonary edema or hypercapnic COPD exacerbations 6
Contraindications to NAV ▪ Cardiac or respiratory arrest ▪ Inability to cooperate, protect the airway, or clear secretions ▪ Severely impaired consciousness ▪ Non-respiratory organ failure that is acutely life threatening ▪ Facial surgery, trauma, or deformity ▪ High aspiration risk ▪ Prolonged duration of mechanical ventilation anticipated ▪ Recent esophageal anastomosis 7
Modes of ventilation NIV refers to two types of ventilator support: 1. Continuous positive airway pressure (CPAP) 2. Noninvasive positive pressure ventilation (NIPPV) 8
Bilevel positive airway pressure Bilevel positive airway support (BPAP), as the name implies, delivers two set levels of positive airway pressure ▪ one during inspiration (IPAP) ▪ and one during expiration (EPAP) 9
Bilevel positive airway pressure 10
Bilevel positive airway pressure ▪ When the ventilator detects inspiratory flow, it delivers a higher inspiratory pressure until sensing a reduction in flow or when reaching a set inspiratory time limit ▪ When inspiration terminates (based on flow or time), the device cycles to a lower expiratory pressure 11
BPAP ▪ Often BPAP is incorrectly referred to as "BiPAP" ▪ However, BiPAP is the name of a portable ventilator manufactured by Respironics Corporation; it is just one of many ventilators that can deliver BPAP 12
Advantages of BPAP  May reverse impending respiratory failure and avoid intubation  Reduced risk of nosocomial pneumonia  Buys time while reversing hypercapnia and cardiogenic pulmonary edeama 13
Disadvantages of BPAP ▪ Facial and nasal pressure injury and sores ▪ Gastric distension ▪ Dry mucous membranes and thick secretions ▪ Aspiration of gastric contents 14
BPAP ▪ BPAP is often selected for patients in need of a greater level of respiratory support, including those who do not show timely improvement with CPAP ▪ With higher mean airway pressures, bilevel support is likely to better address hypoxemia ▪ In addition, the increased support during inspiration can further offload work of breathing, increase tidal volume ventilation, and more rapidly assist with managing hypercapnia 15
Initial settings ▪ Initial settings should be viewed as a starting point that requires careful monitoring and adjustment to maximize the effectiveness of NIV 16
Initial settings ▪ BPAP is often initiated with an expiratory PAP (EPAP) of approximately 5 cm H2O and an inspiratory PAP (IPAP) of 8 to 10 cm H2O. ▪ These pressures can be titrated up depending upon clinical and physiologic response and patient comfort ▪ Final IPAP pressures of 15 to 22 cm H2O are common 17 1. Akingbola OA, Hopkins RL. Pediatric noninvasive positive pressure ventilation. Pediatr Crit Care Med 2001; 2:164. 2. Mayordomo-Colunga J, Medina A, Rey C, et al. Non-invasive ventilation in pediatric status asthmaticus: a prospective observational study. Pediatr Pulmonol 2011; 46:949. 3. Abadesso C, Nunes P, Silvestre C, et al. Non-invasive ventilation in acute respiratory failure in children. Pediatr Rep 2012; 4:e16.
Modes of BPAP ▪ S (Spontaneous) – device triggers IPAP when flow sensors detect spontaneous inspiratory effort and then cycles back to EPAP ▪ T (Timed) – IPAP/EPAP cycling is purely machine- triggered, at a set rate, typically expressed in breaths per minute ▪ S/T (Spontaneous/Timed) – Like spontaneous mode, the device triggers to IPAP on patient inspiratory effort. But in spontaneous/timed mode a "backup" rate is also set to ensure that patients still receive a minimum number of breaths per minute if they fail to breathe spontaneously. 18
Monitoring BiPAP ▪ Look at Patient-HR, RR, BP ▪ Increasing pCO2 a bad sign ▪ Worsening Hypoxemia a bad sign 19
Assessment of effectiveness Improvement in: 1. Respiratory rate and heart rate 2. Dyspnea 3. O requirement 4. Hypercarbia 20
Weaning BiPAP ▪ May slowly reduce both inspiratory and expiratory pressures ▪ May alternatively just switch to simple supplemental Oxygen 21
Clinical studies 22
▪ The aim of this study is to evaluate outcomes of BiPAP therapy in patients with pneumonia ▪ to guide future treatment recommendations and quality improvement
Findings ▪ Data from 81 patients was analyzed ▪ 51% men, mean age 68yrs, mean BMI 28, mean LOS was 10 days and mean hours on BiPAP was 35hrs 24
Findings ▪ Pleural effusions were noted in 63% of patients ▪ All patients with post-obstructive pneumonia died ▪ Intubation rate was 28% ▪ Overall mortality was 25% ▪ Preliminary analysis showed higher intubation rates with > 24hrs on BiPAP (p = 0.016) ▪ Odds of death with pleural effusion was 4.7 (p=0.028) ▪ The odds of death with hypoxic hypercarbic respiratory failure with pleural effusions was 4.05 greater than without pleural effusions (p = 0.022) 25
Conclusion ▪ There has been little evidence and mixed results regarding the use of BiPAP in pneumonia. ▪ Preliminary results show that overall mortality is worse in post-obstructive pneumonia, pleural effusions, hypoxic hypercarbic respiratory failure with effusions and > 24hrs on BiPAP therapy. ▪ Therefore, when BiPAP therapy is used in selected patients with pneumonia, it may provide improved outcomes, patient safety and quality improvement 26
▪ Retrospective analysis on pediatric patients with ARF in the PICU from 2013 – 2015: ▪ evaluating the success of BiPAP in treating ARF from 8 diagnostic categories. 27
Aim ▪ to determine whether more patients within each diagnosis category were successfully treated with BiPAP (BiPAP group) ▪ compared with those who failed therapy with BiPAP, requiring invasive mechanical ventilation (IMV) after initial therapy with BiPAP (BiPAP+IMV group) 28
Findings 291 patients were included in this analysis: ▪ 247 received BiPAP alone ▪ 44 failed BiPAP therapy 29
Findings ▪ In patients with ARF secondary to altered mental status, ARDS, bronchiolitis, ARF following planned surgery with restrictive lung disease, pneumonia, acute chest syndrome, and status asthmaticus a significantly greater number of people were successfully treated with BiPAP alone (all p values < 0.05) ▪ In patients with ARF secondary to sepsis, BiPAP was not an effective therapy in preventing progression to IMV 30
COPD exacerbation ▪ High quality evidence (randomized trials, meta-analyses) indicates that bilevel NIV improves important clinical outcomes in patients having an acute exacerbation of COPD complicated by hypercapnic acidosis 31
32 Objectives: ▪ To determine the efficacy of NPPV in the management of patients with respiratory failure due to an acute exacerbation of COPD
33 Findings: 1. NPPV resulted in decreased mortality 2. decreased need for intubation 3. reduction in treatment failure 4. rapid improvement within the first hour in pH, PaCO2 and respiratory rate 5. In addition, complications associated with treatment and length of hospital stay was also reduced in the NPPV group
34 Conclusion: ▪ Shows benefit of NPPV as 1st line intervention as an adjunct therapy to usual medical care in all suitable patients for the management of respiratory failure secondary to an acute exacerbation of COPD ▪ NPPV should be considered early in the course of respiratory failure and before severe acidosis ensues, as a means of reducing the likelihood of endotracheal intubation, treatment failure and mortality.
Cardiogenic pulmonary edema ▪ There is high quality evidence from meta- analyses and randomized trials that NIV decreases the need for intubation and improves respiratory parameters (heart rate, dyspnea, hypercapnia, acidosis) in patients with cardiogenic pulmonary edema ▪ Several studies suggest that NIV may be particularly beneficial to patients with hypercarbia 35
▪ A 2013 meta-analysis of 32 studies (2916 patients) that included both modalities of NIV (CPAP and BPAP) reported that: ▪ compared with standard medical care, NIV significantly reduced hospital mortality in patients with cardiogenic pulmonary edema 36
Hypoxemic respiratory failure ▪ There is conflicting evidence about whether NIV is advantageous in patients with hypoxemic respiratory failure ▪ Several studies suggest that NIV is beneficial to such patients 37
Metaanalysis (8 randomized trials, 461 patients) compared: ▪ standard medical therapy alone ▪ to standard medical therapy + NIV in patients with hypoxemic respiratory failure due to causes other than cardiogenic pulmonary edema 38
NIV reduced: ▪ ICU mortality (17% absolute risk reduction) ▪ intubation rate (23% absolute risk reduction) ▪ ICU length of stay (2 days - absolute reduction) 39
Conclusion: ▪ Randomized trials suggest that patients with acute hypoxemic respiratory failure are less likely to require endotracheal intubation when NPPV is added to standard therapy 40
Asthma ▪ Noninvasive ventilation has been shown to be effective in patients with acute respiratory failure due to pulmonary edema and exacerbations of COPD ▪ Its role in an acute asthmatic attack, however, is uncertain ▪ The purpose of this pilot study was to compare conventional asthma treatment with nasal bilevel pressure ventilation (BPV) 41
▪ 30 patients who presented to the emergency department with a severe asthma exacerbation that was not responding to inhaled bronchodilator therapy Patients were randomly assigned to receive: 1. NIV (BPAP mode) (or) 2. sham (subtherapeutic BPAP) 42
NIV was associated with a: 1. Reduction in the rate of hospitalization (18 vs 63%) 2. Increased lung function (80 vs 20% predicted FEV1) 43
Other diseases NIV has been used in other clinical settings, but the results have been variable. ▪ Pre-intubation ▪ Intubation refusal ▪ Palliation of acute respiratory failure ▪ Chest trauma 44
Summary & take home message 45
NIV and BPAP ▪ Close monitoring is needed in all patients receiving NIV with frequent titration to optimize support ▪ Clinical response should occur within the first one to 2 hours after initiation ▪ Patients who fail to improve or stabilize within one-half to two hours should be promptly intubated
NIV and BPAP ▪ Failure to see improvement in respiratory rate, heart rate, work of breathing, pulse oximetry, and/or blood gas indices should prompt escalation in the current level of support or a change in the ventilator support strategy ▪ NIV is generally safe. Most complications are local and related to the tightly fitting mask
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