Adjusting BiPAP Settings After Overnight Pulse Oximetry

Physician Oversight and Responsibility

• The American Academy of Sleep Medicine recommends that the physician who prescribed the BiPAP maintains continuing responsibility for supervision of the patient and must review the overnight pulse oximetry results to determine if settings changes are warranted 2
• The American Academy of Sleep Medicine suggests that when oxygen flow insufficiency is identified, the physician should order formal attended polysomnography for proper titration rather than making blind adjustments based solely on home pulse oximetry data 1, 3

Personnel Who Perform the Actual Adjustments

• The American Academy of Sleep Medicine states that sleep technologists are the most common personnel performing BiPAP titrations during attended polysomnography 1, 4
• The British Thoracic Society indicates that respiratory therapists frequently manage ventilator adjustments in both inpatient and outpatient settings 2, 5
• The British Thoracic Society also notes that trained nurses can successfully set up and maintain NPPV, particularly in ICU/HDU settings 2, 5

Proper Titration Protocol

• The American Academy of Sleep Medicine recommends attended polysomnography in a sleep center for proper titration, not home adjustments 1, 3
• The American Academy of Sleep Medicine suggests that if supplemental oxygen is needed, it should be added only after pressure support (IPAP-EPAP differential) and respiratory rate have been optimized 1
• The American Academy of Sleep Medicine recommends that supplemental oxygen should start at 1 L/minute and be increased in 1 L/minute increments every 5 minutes until SpO2 >90% is achieved 1
• The American Academy of Sleep Medicine notes that pressure support may need to be increased if SpO2 remains below 90% for 5 minutes or more and tidal volume is low 1

Close Follow-Up Requirements

• The American Academy of Sleep Medicine emphasizes that close follow-up after BiPAP initiation by appropriately trained healthcare providers is essential to establish effective utilization patterns, remediate side effects, and assess measures of ventilation and oxygenation to determine if further adjustments are needed 1
• The American Thoracic Society recommends serial evaluation and adjustment of BiPAP as the patient's requirements change over time 3

Common Pitfalls to Avoid

• The American Academy of Sleep Medicine and the American Thoracic Society advise against making blind setting adjustments based solely on home pulse oximetry data without proper attended titration 1, 3
• The American Thoracic Society notes that home pulse oximetry alone is insufficient for determining optimal BiPAP settings—it can detect problems but cannot guide precise pressure adjustments 3