NIV: BiPAP, CPAP & HFNO

• Best indications: acute cardiogenic pulmonary edema, COPD exacerbation with acidosis, plus post-extubation support in high-risk patients.
• Start BiPAP at IPAP 10–15 / EPAP 5, or CPAP 5–10 for APE; HFNO is the alternative for hypoxemia.
• Reassess at 1 h; intubate if pH, RR, GCS, or gas exchange worsen or fail to improve. Use NIV cautiously in pneumonia/ARDS with close monitoring, and intubate promptly if there is no early improvement or clinical deterioration.
• Skip NIV with vomiting, facial trauma, an unprotected airway, or immediate arrest.

Initiating BiPAP in a Patient With a COPD Exacerbation

• COPD exacerbation patient meeting two of: respiratory distress with moderate-to-severe dyspnea · arterial pH <7.35 with PaCO₂ >45
• Adjuncts: oxygen · bronchodilators · steroids · antibiotics
• Check for NIV contraindications
• Contraindication found?
• Intubate if clinically indicated
• Raise head of bed · explain the intervention · choose an appropriately sized full face mask and head strap · ensure monitoring and respiratory therapy coverage · apply the mask loosely
• Begin at IPAP 10, EPAP 5; titrate FiO₂ for SpO₂ 88–92%; backup rate 12–14 · raise IPAP in 2–3 cm H₂O increments to goal — max IPAP 20–25 cm H₂O recommended · recheck often for leak and adjust mask
• Improving? (respiratory rate down, less distress · PaCO₂ and pH improving — check ABG after 1 hour of NIV · good ventilator synchrony)
• Continue NIV plus adjunctive therapies · reassess condition frequently
• Intubate if clinically indicated