BiPAP Management for Hypercapnic Respiratory Failure

Initial BiPAP Settings

The British Thoracic Society recommends starting BiPAP with IPAP of 10-15 cmH2O and EPAP of 4-5 cmH2O, targeting SpO2 88-92%, in patients with severe COPD and hypercapnic respiratory failure 1, 2
The American Thoracic Society suggests setting IPAP to provide adequate tidal volumes of 6-8 mL/kg ideal body weight while avoiding barotrauma 1
The European Respiratory Society recommends setting EPAP at 4-5 cmH2O as the starting point to minimize the risk of worsening dynamic hyperinflation in obstructive disease 1

The American College of Chest Physicians recommends rechecking arterial blood gas at 30-60 minutes after initiating BiPAP to assess response and detect worsening acidosis 2, 3
The British Thoracic Society suggests monitoring for pH <7.26 as this is the critical threshold requiring consideration for invasive mechanical ventilation 4, 5, 6
The European Respiratory Society recommends assessing for patient-ventilator asynchrony by observing respiratory rate, patient comfort, and chest wall movement 1

The American Heart Association recommends maintaining semi-recumbent position at 30-45 degrees to reduce pulmonary congestion and improve diaphragmatic function in patients with heart failure 2
The European Society of Cardiology suggests considering diuretics to reduce pulmonary edema that may be contributing to hypercapnia 2
The American Thoracic Society recommends being cautious with PEEP/EPAP as excessive levels may reduce venous return and cardiac output in heart failure 1

The British Thoracic Society recommends targeting pH 7.2-7.4 rather than normalizing PCO2 as permissive hypercapnia is well-tolerated and reduces risk of barotrauma 1
The American Thoracic Society suggests that the higher the pre-morbid PCO2, the higher the acceptable target PCO2 should be 1
The European Respiratory Society recommends that peak airway pressure >30 cmH2O should trigger acceptance of permissive hypercapnia rather than increasing pressures further 1

The American College of Chest Physicians recommends administering short-acting β2-agonists to reduce airflow obstruction 2
The European Respiratory Society suggests giving methylprednisolone for COPD/asthma exacerbation component 2
The American Thoracic Society recommends maintaining electrolytes to optimize respiratory muscle function 2
The European Society for Clinical Nutrition and Metabolism suggests providing adequate nutrition to prevent malnutrition common in COPD 2

The American Thoracic Society recommends proceeding to intubation and invasive mechanical ventilation if pH remains <7.26 after 30-60 minutes of optimized BiPAP therapy with medical management, unless the patient's premorbid state, quality of life, and goals of care indicate that invasive ventilation would not be appropriate given the severe co-morbidities 4, 5, 6