Bpap (bi level positive airway pressure)

An overview of non-invasive ventilation. Its uses, contraindications, settings and the clinical studies.

1. BPAP
Bilevel 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 H
2O and an
inspiratory PAP (IPAP) of 8 to 10 cm H
2O.
▪These pressures can be titrated up depending
upon clinical and physiologic response and
patient comfort
▪Final IPAP pressures of 15 to 22 cm H
2O 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 pCO
2 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,
PaCO
2 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 1
st
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
FEV
1)
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