BiPAP Use in Pulmonary Embolism

Key Principles

• The European Society of Cardiology recommends that positive intrathoracic pressure induced by mechanical ventilation may reduce venous return and worsen right ventricular (RV) failure in patients with massive pulmonary embolism 1, 2, 3
• The American Thoracic Society suggests that positive end-expiratory pressure (PEEP) should be applied with caution in pulmonary embolism patients to avoid decreasing venous return to an already failing right ventricle 1, 2, 3

Risk-Stratified Approach to BiPAP in PE

• In patients with shock or hypotension, the European Society of Cardiology recommends intubation should be performed only if the patient cannot tolerate non-invasive ventilation, with a preference for non-invasive ventilation or high-flow nasal cannula over invasive mechanical ventilation 2
• The European Society of Cardiology advises that if BiPAP is used in high-risk patients, minimal PEEP settings should be applied and the patient should be monitored closely for hemodynamic deterioration 1, 2

Specific BiPAP Settings When Used

• The European Society of Cardiology recommends using low tidal volumes (approximately 6 mL/kg lean body weight) and keeping end-inspiratory plateau pressure <30 cm H2O when using BiPAP in pulmonary embolism patients 1, 2, 3
• The European Society of Cardiology suggests minimizing PEEP to reduce impact on venous return and considering starting with lower inspiratory pressures and titrating cautiously 1, 2

Alternative Respiratory Support Options

• The European Society of Cardiology recommends high-flow nasal cannula oxygen as a preferred alternative to BiPAP in high-risk pulmonary embolism patients, as it reduces work of breathing without significant positive pressure 2

Critical Clinical Pearls

• The European Society of Cardiology advises that the decision to use BiPAP should never delay definitive pulmonary embolism treatment, such as anticoagulation, thrombolysis, or embolectomy in appropriate patients 2
• The European Society of Cardiology recommends avoiding aggressive fluid resuscitation in pulmonary embolism patients requiring respiratory support, as this can worsen right ventricular function 1, 2