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bilevel positive airway pressure (BiPAP)

Indications: 1) acute respiratory failure (1st line) [12] - reduces need for endotracheal intubation - relative to endotracheal intubation - reduces mortality - does not improve neurologic status 2) chronic hypercapneic respiratory failure [2,4] - acute on chronic hypercapneic respiratory failure [2,4] 3) heart failure & cardiogenic pulmonary edema [5,6] - more effective than CPAP alone [5] - reduces the risk of endotracheal intubation & death - does not protect against a new myocardial infarction. - no data that CPAP reduces stroke reduces need for balloon pump or coronary revascularization [11] 4) sleep-related hypoventilation syndromes - end-stage respiratory failure due to neuromuscular disease 5) complex sleep apnea [9] - efficacy of BiPAP relative to CPAP for routine treatment of obstructive sleep apnea has not been established [2] 6) non-invasive ventilation in postoperative management 7) general a) will wear mask b) hemodynamically stable c) alert, awake Contraindications: - general - will not wear mask - hemodynamically unstable - obtunded, stuperous, coma - does not improve exercise capacity in patients with COPD [3] Benefit/risk: - see non-invasive positive pressure ventilation Procedure: - both inspiratory & expiratory pressure are applied by a mask during the respiratory cycle - the inspiratory & expiratory pressures are set independently [2] - like CPAP, may be used as nocturnal procedure Special laboratory: - polysomnography may be helpful to establish optimal inspiratory & expiratory pressures for nocturnal BiPAP Mechanism of action: - inspiratory support decreases work of breathing. - expiratory support (CPAP) improves gas exchange by preventing alveolar collapse - nocturnal BiPAP decreases nocturnal pCO2, daytime pCO2, & sleepiness - benefit in heart failure may be due to neural changes, not simply alteration of preload [5]

General

non-invasive positive pressure ventilation (NPPV)

References

  1. Manual of Medical Therapeutics, 28th ed, Ewald & McKenzie (eds), Little, Brown & Co, Boston, 1995, pg 189
  2. Medical Knowledge Self Assessment Program (MKSAP) 14, 16, 17. American College of Physicians, Philadelphia 2006, 2012, 2015
  3. Moga AM, de Marchie M, Saey D, Spahija J. Bi-level Positive Airway Pressure (BiPAP) with Standard Exhalation Valve Does Not Improve Maximum Exercise Capacity in Patients with COPD. COPD. 2014 Jun 19. [Epub ahead of print] PMID: 24946024
  4. Galli JA, Krahnke JS, James Mamary A et al Home non-invasive ventilation use following acute hypercapnic respiratory failure in COPD. Respir Med. 2014 May;108(5):722-8. PMID: 24702885
  5. Yoshida M, Kadokami T, Momii H et al Enhancement of cardiac performance by bilevel positive airway pressure ventilation in heart failure. J Card Fail. 2012 Dec;18(12):912-8 PMID: 23207079
  6. Vital FM, Ladeira MT, Atallah AN Non-invasive positive pressure ventilation (CPAP or bilevel NPPV) for cardiogenic pulmonary oedema. Cochrane Database Syst Rev. 2013 May 31;5:CD005351. PMID: 23728654
  7. Hardiman O. Management of respiratory symptoms in ALS. J Neurol. 2011 Mar;258(3):359-65 PMID: 21082322
  8. Bach JR, Goncalves MR, Hon A et al Changing trends in the management of end-stage neuromuscular respiratory muscle failure: recommendations of an international consensus. Am J Phys Med Rehabil. 2013 Mar;92(3):267-77. Review. PMID: 23051760
  9. Kusniar TJ, Morgenthaler TI Treatment of complex sleep apnea syndrome. Chest. 2012 Oct;142(4):1049-57 PMID: 23032455
  10. Chiumello D, Chevallard G, Gregoretti C. Non-invasive ventilation in postoperative patients: a systematic review. Intensive Care Med. 2011 Jun;37(6):918-29. Review. PMID: 21424246
  11. Weng CL, Zhao YT, Liu QH, et al. Meta-analysis: Noninvasive ventilation in acute cardiogenic pulmonary edema. Ann Intern Med. 2010;152(9):590-600 PMID: 20439577
  12. Nava S, Grassi M, Fanfulla F, et al. Non-invasive ventilation in elderly patients with acute hypercapnic respiratory failure: a randomised controlled trial. Age Ageing. 2011; 40:444-450 PMID: 21345841