BiPAP Titration Guidelines

Initial Settings

The American Academy of Sleep Medicine recommends starting with IPAP of 8 cm H₂O and EPAP of 4 cm H₂O, maintaining a minimum pressure differential of 4 cm H₂O between inspiratory and expiratory pressures for adult and pediatric patients requiring BiPAP 1, 2
The initial maximum IPAP-EPAP differential should be 10 cm H₂O 1, 2

Increase IPAP and/or EPAP by at least 1 cm H₂O increments with intervals no shorter than 5 minutes to eliminate obstructive respiratory events 1, 2, 3
For obstructive apneas, increase both IPAP and EPAP if ≥1 apnea in patients <12 years or ≥2 apneas in patients ≥12 years 2, 3
For hypopneas, increase IPAP if ≥1 hypopnea in patients <12 years or ≥3 hypopneas in patients ≥12 years 2, 3
For RERAs, increase IPAP if ≥3 RERAs in patients <12 years or ≥5 RERAs in patients ≥12 years 2, 3

Continue upward titration until achieving at least 30 minutes without breathing events, ideally including at least 15 minutes in supine REM sleep 1, 3

Use ST mode with backup rate if the patient demonstrates frequent and significant central apneas at baseline or during titration, inappropriately low respiratory rate, or failure to reliably trigger IPAP/EPAP transitions due to muscle weakness 4
Set the initial backup rate equal to or slightly less than the patient's spontaneous sleeping respiratory rate (minimum 10 breaths per minute) 4

Patients with elevated BMI or those undergoing retitration may benefit from higher starting IPAP or EPAP, though specific methodology for determining these pressures a priori lacks strong evidence 1, 2
Exercise caution with BiPAP in spontaneously breathing patients, as BiPAP can increase work of breathing and respiratory muscle effort compared to pressure support ventilation 3
BiPAP is indicated when patients are uncomfortable or intolerant of high CPAP pressures, or when obstructive events persist at CPAP of 15 cm H₂O 2