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REBEL Core Cast 148.0âDemystifying Non-Invasive Ventilation & HiFlow
REBEL Cast
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When to use BiPAP versus CPAP
Frank and Dr. Eric outline typical indications: BiPAP for low tidal volumes/hypercapnia, CPAP for hypoxemia and alveolar recruitment.
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đ§ REBEL Rundown
đď¸ Key Points
- đ¨ NIV = Support without a tube: CPAP, BiPAP, and HFNC improve oxygenation and reduce the work of breathing.
- đŤ CPAP = Continuous pressure: Best for hypoxemic patients (e.g., pulmonary edema, OSA).
ď¸ BiPAP = Two pressures (IPAP/EPAP): Great for hypercapnic failure (e.g., COPD, obesity hypoventilation).- đŹď¸ HFNC = Heated, humidified high flow: Reduces effort, improves comfort, and enhances oxygen delivery.
- 𩺠Supportive, not definitive: NIV stabilizes patients while the underlying cause is treated.
đ Introduction
Non-invasive ventilation (NIV) refers to respiratory support provided without endotracheal intubation. The most common modalities include continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP), and high-flow nasal cannula (HFNC). These therapies aim to improve oxygenation, reduce the work of breathing, and potentially prevent invasive mechanical ventilation.
đ¨ CPAP and BiPAP
- CPAP delivers a single, continuous pressure during inspiration and expiration. This pressure (commonly 5â10 cm HâO) helps recruit atelectatic alveoli, reduce shunt, and improve oxygenation. It is commonly used for conditions like pulmonary edema, obstructive sleep apnea, or mild hypoxemia without significant ventilatory failure.
- BiPAP alternates between two pressures:
- Inspiratory positive airway pressure (IPAP), augments tidal volume and unloads inspiratory muscles.
- Expiratory positive airway pressure (EPAP), maintains alveolar recruitment and improves oxygenation.
The differential between IPAP and EPAP is critical for reducing hypercapnia in patients with COPD exacerbations or acute hypercapnic respiratory failure.
- Indications
- CPAP: hypoxemia without major ventilatory failure (e.g., cardiogenic pulmonary edema, atelectasis, OSA).
- BiPAP: hypercapnia with increased work of breathing (e.g., COPD exacerbation, neuromuscular weakness, obesity hypoventilation).
A helpful way to conceptualize CPAP and BiPAP is through the hairdryer analogy. Imagine placing a hairdryer in your mouth:
𩺠Clinical Considerations
- Masks can be uncomfortable, impair secretion clearance, and limit oral intake.
- Some patients require sedation to tolerate NIV, but this carries risks in patients with unprotected airways.
- NIV is thus a high-stakes intervention requiring close monitoring.
- Common starting dose to understand titration, but start at the level appropriate for your patient: IPAP 10 cm HâO / EPAP 5 cm HâO (â10/5â) and are titrated:
- Increase IPAP to improve tidal volume and COâ clearance.
- Increase EPAP to recruit alveoli and improve oxygenation.
- Both may be raised simultaneously if the patient is both hypoxemic and hypercapnic.
đ High-Flow Nasal Cannula (HFNC)
- H: Heated & humidified â improves mucociliary clearance, prevents airway drying, and enhances tolerance. I: Inspiratory flow â high flow meets or exceeds patient demand, reducing respiratory rate and effort.
- F: Functional residual capacity â modest generation of positive end-expiratory pressure (PEEP), promoting alveolar recruitment.
- L: Lighter â generally more comfortable and less restrictive than mask-based NIV.
- O: Oxygen dilution â minimizes entrainment of room air, delivering higher and more predictable FiOâ.
- W: Washout â flushes anatomical dead space, reducing COâ rebreathing.
- HFNC delivers heated, humidified oxygen at high flow rates (30â60 L/min) through wide-bore nasal prongs. A mnemonic, H-I-F-L-O-W, helps summarize its mechanisms:
- Indications: Traditionally used for acute hypoxemic respiratory failure (e.g., pneumonia), HFNC is increasingly studied for hypercapnic failure as well, with trials suggesting non-inferiority to BiPAP in select populations.
Post Peer Reviewed By: Marco Propersi, DO (Twitter/X: @Marco_propersi), and Mark Ramzy, DO (X: @MRamzyDO)
đ¤ Show Notes
Syed Moosi Raza, MD
PGY 3 Internal Medicine Resident
Cape Fear Valley Internal Medicine Residency Program
Fayetteville NC
Aspiring Pulmonary Critical Care Fellow
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