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.

1. BPAPBilevel positive airway pressure

2. Contents
▪ Introduction
▪ Uses and contraindications
▪ BPAP settings and monitoring
▪ Clinical studies
▪ Summary and take home message

3. 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

4. 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

5. 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

6. NAV use
▪ Despite evidence of efficacy, NIV may be
underutilized among patients with
cardiogenic pulmonary edema or
hypercapnic COPD exacerbations
6

7. 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

8. Modes of ventilation
NIV refers to two types of ventilator support:
1. Continuous positive airway pressure (CPAP)
2. Noninvasive positive pressure ventilation (NIPPV)
8

9. 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

10. Bilevel positive airway pressure
10

11. 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

12. 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

13. 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

14. Disadvantages of BPAP
▪ Facial and nasal pressure injury and
sores
▪ Gastric distension
▪ Dry mucous membranes and thick
secretions
▪ Aspiration of gastric contents
14

15. 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

16. Initial settings
▪ Initial settings should be viewed as a
starting point that requires careful
monitoring and adjustment to maximize
the effectiveness of NIV
16

17. 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.

18. 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

19. Monitoring BiPAP
▪ Look at Patient-HR, RR, BP
▪ Increasing pCO2 a bad sign
▪ Worsening Hypoxemia a bad sign
19

20. Assessment of effectiveness
Improvement in:
1. Respiratory rate and heart rate
2. Dyspnea
3. O requirement
4. Hypercarbia
20

21. Weaning BiPAP
▪ May slowly reduce both inspiratory and
expiratory pressures
▪ May alternatively just switch to simple
supplemental Oxygen
21

22. Clinical
studies
22

23. ▪ The aim of this study is to evaluate
outcomes of BiPAP therapy in patients
with pneumonia
▪ to guide future treatment
recommendations and quality
improvement

24. 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

25. 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

26. 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

27. ▪ 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

28. 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

29. Findings
291 patients were included in this analysis:
▪ 247 received BiPAP alone
▪ 44 failed BiPAP therapy
29

30. 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

31. 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. 32
Objectives:
▪ To determine the efficacy of NPPV in the
management of patients with respiratory failure
due to an acute exacerbation of COPD

33. 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. 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.

35. 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

36. ▪ 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

37. 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

38. 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

39. NIV reduced:
▪ ICU mortality (17% absolute risk reduction)
▪ intubation rate (23% absolute risk reduction)
▪ ICU length of stay (2 days - absolute reduction)
39

40. 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

41. 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

42. ▪ 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

43. 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

44. 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

45. Summary &
take home
message
45

46. 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

47. 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

48. 48

49. 49