Initial Settings for BPAP ST

Configuration of Initial Pressures

The American Academy of Sleep Medicine recommends starting with IPAP of 8 cm H₂O and EPAP of 4 cm H₂O, with a backup respiratory rate equal to or slightly less than the patient's spontaneous respiratory rate during sleep (minimum 10 breaths/minute), and an inspiratory time that achieves a ratio of I:E of approximately 1:2 1, 2
Initial IPAP should be 8 cm H₂O in pediatric and adult patients 1, 3, 4
Initial EPAP should be 4 cm H₂O in pediatric and adult patients 1, 3, 4
Maintain a minimum difference of at least 4 cm H₂O between IPAP and EPAP 1, 5
Do not exceed a difference of 10 cm H₂O between IPAP and EPAP 1, 5

In patients with high BMI, consider starting with higher IPAP or EPAP pressures than standard values 1, 3
For retitration studies, also consider selecting higher initial pressures 1, 3

Initial frequency should be equal to or slightly less than the patient's spontaneous respiratory rate during sleep, with a minimum of 10 breaths/minute 2
If the patient's sleep respiratory rate is unknown, use the spontaneous respiratory rate during wakefulness 2
Increase the backup frequency in increments of 1-2 breaths/minute as needed 2

For patients with obstructive disease (COPD), use a shorter inspiratory time, approximately 30% of the cycle time (%IPAP time) 2, 6
For patients with restrictive disease, use a longer inspiratory time, approximately 40% of the cycle time 2

For obstructive apneas, increase both IPAP and EPAP if ≥2 obstructive apneas are observed in patients ≥12 years old 1, 4
For hypopneas, increase IPAP if ≥3 hypopneas are observed in patients ≥12 years old 1, 3
For RERAs (respiratory effort-related arousals), increase IPAP if ≥5 RERAs are observed in patients ≥12 years old 1, 4
For snoring, may increase IPAP if ≥3 minutes of loud snoring are observed in patients ≥12 years old 1

If the patient has chronic alveolar hypoventilation (not just obstructive sleep apnea), ST mode is preferred because these patients may not activate the IPAP/EPAP cycle during inappropriately long periods or may have inadequate respiratory rate to provide sufficient minute ventilation 2

In patients with COPD or obstructive disease, insufficient expiratory time can cause air trapping and auto-PEEP 6, 7
Ensure a ratio of I:E of approximately 1:2 or greater 2, 6

If central apneas appear during titration, consider decreasing IPAP or adjusting the BPAP mode to spontaneous-timed with backup frequency 1, 3

If the patient wakes up and complains that the pressure is too high, restart at a lower pressure that the patient reports as comfortable to allow return to sleep 3, 5

If supplemental oxygen is required, maintain a target saturation of 88-92% in patients with COPD to avoid worsening hypercapnia 6
The effective FiO₂ decreases as IPAP or EPAP increases due to increased intentional leak 8