Go / no-go checklist
Tick anything that applies. Any contraindication = intubate.
Hold — finish readiness checklist first
0 contraindications · 0/9 readiness items
Contraindications (any = stop)
Readiness
Quick starting-settings calculator
Recommended startBiPAP
- IPAP
- 10 cmH₂O
- EPAP
- 5 cmH₂O
- Pressure support
- 5 cmH₂O
- FiO₂
- 100% → wean
- SpO₂ target
- 92–96%
- Reasonable starting point while you reassess.
- Reassess clinical status & gas in 30–60 min.
Starting points only — titrate to clinical response and gas exchange. Always confirm contraindications first.
1-hour ABG/VBG titration helper
Enter the recheck gas and current pressures. Suggests an IPAP/EPAP adjustment and FiO₂ action.
Enter at least one gas value (pH, PaCO₂, PaO₂, or SpO₂) to see a suggestion.
Decision support only — interpret in clinical context. Targets vary (e.g., COPD SpO₂ 88–92%). Reassess in 30–60 min after any change.
BiPAP vs CPAP — pick one
- CPAP = single continuous pressure. Best for oxygenation problems with intact ventilation: cardiogenic pulmonary edema, OSA, drowning.
- BiPAP = IPAP (inspiration) + EPAP (expiration). Best when the patient also needs help moving air: COPD exacerbation, asthma, hypercapnic respiratory failure, neuromuscular weakness, mixed CHF/COPD.
- Pressure support = IPAP − EPAP. That difference is what augments tidal volume and blows off CO₂.
Indications
- COPD exacerbation with respiratory acidosis (pH < 7.35, PaCO₂ > 45) — strongest evidence.
- Acute cardiogenic pulmonary edema — reduces preload/afterload, improves oxygenation, reduces intubation rate.
- Hypoxemic respiratory failure (selected): pneumonia, post-extubation, immunocompromised.
- Asthma — adjunct while bronchodilators take effect.
- DNI patient as ceiling of care.
- Pre-oxygenation prior to intubation in shunt physiology.
Contraindications (intubate instead)
- Cardiac or respiratory arrest.
- Inability to protect the airway / depressed mental status / vomiting.
- Facial trauma, burns, or anatomy preventing mask seal.
- Recent upper GI surgery, active UGI bleeding, bowel obstruction.
- Hemodynamic instability / shock not responsive to resuscitation.
- Undrained pneumothorax.
- High aspiration risk.
Starting settings — common scenarios
Default BiPAP start
- IPAP 10 cmH₂O
- EPAP 5 cmH₂O
- FiO₂ 100% → wean to SpO₂ 92–96%
- Rate (backup) 10–12 if S/T mode
Pressure support = 5. Reasonable starting point for most patients while you reassess.
COPD exacerbation
- IPAP 10–12, EPAP 4–5
- Goal PS 8–10 (titrate IPAP up by 2 q5–10 min)
- FiO₂ to SpO₂ 88–92% (avoid over-oxygenation)
- Target: ↓ RR, ↓ accessory muscle use, ↑ pH
Keep EPAP low — high EPAP worsens auto-PEEP and air trapping.
Acute pulmonary edema (CHF)
- CPAP 8–10 cmH₂O (first line) — or
- BiPAP IPAP 10–12 / EPAP 5–8
- FiO₂ 100% → wean to SpO₂ 94–98%
Higher EPAP reduces preload/afterload. Concurrent nitrates and diuresis.
Hypoxemic failure (pneumonia, ARDS-lite)
- IPAP 12–14, EPAP 6–8
- FiO₂ 100% then titrate
High failure rate — set a clear 1–2 hr time-limited trial; intubate early if no improvement.
Asthma
- IPAP 8–10, EPAP 3–5
- Continue back-to-back nebs through the mask
Adjunct only — does not replace bronchodilators / steroids / Mg.
How to titrate (every 5–10 min)
- Hypercapnia / high CO₂ / acidosis → increase IPAP by 2 cmH₂O (raises pressure support → bigger tidal volume → blows off CO₂). Typical max 20.
- Hypoxemia → increase EPAP by 2 cmH₂O (recruits alveoli, ↑ FRC) and/or ↑ FiO₂. Keep IPAP − EPAP ≥ 4 to maintain pressure support. Typical EPAP max 10–12.
- Patient-ventilator dyssynchrony → check mask seal, adjust rise time / trigger sensitivity, coach the patient.
- Excessive tidal volume / barotrauma risk → lower IPAP. Aim Vt ~6–8 mL/kg IBW.
- Recheck ABG/VBG at 1 hour. Improvement in pH / PaCO₂ predicts success.
Monitoring
- Continuous SpO₂, ETCO₂ (if available), telemetry, BP q5–15 min initially.
- VBG/ABG at baseline and at 1 hour.
- RR, accessory muscle use, mental status, mask seal, patient comfort.
- Reassess for pneumothorax, hypotension from positive pressure, gastric distention.
Signs of failure → intubate
- No improvement in pH or PaCO₂ at 1 hour.
- Worsening mental status, agitation, or inability to tolerate the mask.
- Persistent SpO₂ < 90% on FiO₂ 100% with maximized EPAP.
- Hemodynamic instability, arrhythmia, ischemia.
- Inability to clear secretions, vomiting, aspiration.
Troubleshooting
- Mask leak: resize, refit, loosen straps slightly (over-tight = more leak), consider full-face mask.
- Claustrophobia / agitation: coach, dexmedetomidine 0.2–0.7 mcg/kg/hr or low-dose ketamine; avoid heavy benzos.
- Gastric distention: NG tube if prolonged use; lower IPAP if > 20.
- Hypotension: usually from ↑ intrathoracic pressure / preload drop — fluid bolus, lower EPAP.
- Skin breakdown (nasal bridge): hydrocolloid dressing prophylactically.
Pearls
- "IPAP for ventilation (CO₂), EPAP for oxygenation (O₂)."
- Best evidence: COPD exacerbation and cardiogenic pulmonary edema. Use liberally there, cautiously elsewhere.
- Set a time-limited trial (1–2 hr). If not better, intubate — delayed intubation worsens outcomes.
- Don't oversaturate COPD patients — target SpO₂ 88–92%.
- Always have intubation gear at the bedside before starting NIV.
Educational reference only. Always follow current institutional protocols and clinical judgment.