Respiratory Alkalosis Management

Non-Invasive Ventilation

• The American College of Emergency Physicians suggests that CPAP is less effective than BiPAP for respiratory alkalosis as it doesn't provide the same level of control over ventilation, while the National Comprehensive Cancer Network recommends reserving mechanical ventilation for cases where BiPAP fails 1, 2
• BiPAP therapy is recommended for patients with sleep apnea who are intolerant of high CPAP pressures or have continued obstructive respiratory events, with initial settings of IPAP 8 cm H2O and EPAP 4 cm H2O, and a recommended IPAP-EPAP differential of 4-10 cm H2O, as suggested by the American Academy of Sleep Medicine 3
• Initial BiPAP settings and adjustments are as follows:

• The goal of titration is to reduce the respiratory disturbance index (RDI) to <5 per hour for at least 15 minutes, and to achieve an SpO2 >90%, with titration aiming to maintain leak within acceptable parameters and reduce RDI ≤10 per hour or by 50% if baseline RDI <15 3
• Close monitoring after initiation is essential for establishing effective utilization patterns, and follow-up should be done within the first two weeks of therapy initiation, with regular monitoring of therapy effectiveness, including residual AHI, device usage, and symptom improvement, as recommended by multiple guidelines 4, 5, 6
• For obstructive apneas, both IPAP and EPAP should be increased, while for hypopneas, RERAs, and snoring, only IPAP should be increased, with consideration of ST mode with backup rate for treatment-emergent central apneas, and decrease IPAP if central apneas occur 3
• BiPAP therapy is contraindicated in patients with respiratory arrest, inability to protect airway, severe facial trauma or burns, recent facial, esophageal, or gastric surgery, or active hemoptysis, particularly massive hemoptysis, as stated by multiple sources 5, 7, 8
• Patients with gastroesophageal reflux disease may benefit from BiPAP, but with a higher risk of aerophagia, and the American Academy of Sleep Medicine suggests considering nasal masks or nasal pillows instead of full face masks to reduce the risk of aerophagia 3
• Alternative therapies, such as mandibular advancement devices (MADs), positional therapy, and weight loss, may be considered for patients with mild to moderate obstructive sleep apnea (OSA) who cannot tolerate or prefer not to use CPAP therapy, with MADs being the most effective alternative treatment option, as recommended by the European Respiratory Society 9, 10, 11
• Educational interventions at PAP therapy initiation are strongly recommended to improve adherence, and behavioral and/or troubleshooting interventions during the initial period are conditionally recommended to improve adherence, with close follow-up necessary after initiation of BiPAP by appropriately trained healthcare providers to establish effective utilization patterns and remediate side effects 6, 4
• The types of non-invasive ventilation are as follows: