AN

Australian Critical Care

Bi-level positive airway pressure

(BiPAP) a n d acute cardiogenic
pulmonary oedema (ACPO) in the
emergency department
Sarah Murray • RN BN MN (Critical Care)
M a s t e r of Nursing C a n d i d a t e , D e p a r t m e n t Of Clinical Nursing, University of Sydney, NSW
Clinical Nurse Educator
Emergency D e p a r t m e n t , Prince of Wales Hospital, Randwick, NSW

This p a p e r was a w a r d e d the A C C C N B e s t Nursing Review p a p e r in 2001 a n d w a s p r e s e n t e d a t the

World Congress o f Intensive a n d Critical Care Medicine in Sydney, October 2001.

Abstract: Patients in acute respiratory failure (ARF) frequently present to the emergency department (ED). Traditionally management
has involved mechanical ventilation via endotracheal intubation. Such invasive forms of treatment, however, correlate with a higher
incidence of infection, mortality, length of stay and contribute to the costs of intensive care. Non-invasive positive pressure ventilation
(NIPPV) such as [Link] positive airway pressure (BiPAP) may therefore provide an alternative and preferable form of treatment.

Whilst contemporary literature supports the use of BiPAP in hypercapnic ARF, its role in acute hypoxaemic presentations remains
elusive. Specifically, the efficacy and safety of BiPAP in the treatment of acute cardiogenic pulmonary oedema (ACPO) remains a
contentious issue. The aim of this paper is to explore the physiological rationale for treatment of ACPO with BiPAP. Particular
attention will focus on the comparative theoretical advantages of BiPAP in relation to continuous positive airway pressure (CPAP), and
a review of recent research. Discussion will incorporate timeliness in the application of BiPAP, indicators of successful treatment,
appropriate manipulation of pressure settings, nursing workload and management of patients beyond the ED. Whilst the theoretical
advantages of BiPAP ventilation are acknowledged, larger randomised controlled research studies are recommended in order to clearly
ensure its safe and effective application in the treatment of ACPO.

Murray S. Bi-level positive airway pressure (BiPAP) and acute cardiogenic pulmonary oedema (ACPO) in the emergency department. Aust Crit Care
2002; 15(2): 51-63.

INTRODUCTION surrounds the precise mode of NIPPV appropriate for the treatment
of hypoxaemic respiratory failure 6. This apparent uncertainty exists
Acute respiratory failure (ARF) represents deterioration in the
particularly in relation to ACPO. In view of this controversy,
ability of the lungs and muscles of respiration to adequately
critical analysis of NIPPV ventilation in the treatment of ACPO is
maintain gaseous exchange 1.2. Whilst ARF represents a deficiency
clearly warranted.
in the processes of gas exchange, it usually occurs secondary to
another disorder that has altered the functioning of the respiratory Following the commercial availability of continuous positive
system 3. Examples of causative conditions preceding ARF include airway pressure ventilation (CPAP) in the 1980s, the popularity of
acute cardiogenic pulmonary oedema (ACPO)4, exacerbations of NIPPV has evolved secondary to ease of application, effectiveness,
chronic obstructive pulmonary disease (COPD), severe asthma, and the ability to avoid endotracheal intubation 7. Bi-level positive
pneumonia, chronic bronchitis and emphysema 5. Without
airway pressure (BiPAP) represents a relatively new and alternative
treatment, ultimately a decrease in ventilatory drive, muscle
form of NIPPV. However, its specific efficacy in the treatment of
strength, chest wall elasticity and the lungs' capacity for gas
ACPO remains ambiguous when compared to CPAE
exchange or an increase in airway resistance or metabolic oxygen
Consideration will thus be given to the comparative physiological
requirements 3 will likely ensue.
foundations of CPAP and BiPAP, current research in support of
Patients may present to the emergency department (ED) with BiPAP, and the ostensible debate surrounding its use specific to
hypoxaemic and/or hypercapnic forms of respiratory failure. Whilst ACPO. Particular reference is given to the use of BiPAP in the ED,
current research advocates the effectiveness of non-invasive representing the area that patients most frequently present in ARF,
positive pressure ventilation (NIPPV) in the treatment of and hence the area most appropriately at the forefront of such
hypercapnic respiratory failure such as COPD, controversy issues.

51 Volume lS Number2 May2002

 Ab,
Australian Critical Care

LITERATURE REVIEW Conventional methods of NIPPV have primarily involved the use
of CPAE An alternative form of NIPPV that has emerged as a
In view of well established research pertaining to CPAP ventilation promising therapeutic intervention in the treatment of ARF is the
and minimal research available on BiPAP, data sources included use of BiPAP ventilation. Both forms of NIPPV have been
literature searches from MEDLINE (1996-2001) and CINAHL promoted as improving pulmonary mechanics and haemodynamics,
(1996-200t). Only research and review articles published in thereby modifying the pathophysiological process of ARF 4.
English and those currently available in Australia were
incorporated in this review. Key search words included non- CPAP
invasive ventilation, ARF, cardiogenic pulmonary oedema, CPAP is a method of NIPPV whereby the patient breathes via a
emergency and BiPAP. References from selected literature and mask against a continuous positive pressure throughout the
research reviews were also examined for additional articles. respiratory cycle. Physiologically, CPAP improves lung mechanics
by recruiting collapsed (atelectatic) lung units, enhancing
A total of 32 articles published from 1995 to 2001 were reviewed.
pulmonary compliance and reducing the work of breathing 4.
Whilst only a few articles were required to surmise the established
Reports of significant increases in arterial oxygenation and
benefits of CPAP ventilation, articles specific to the use of BiPAP decreases in intrapulmonary shunt and the alveolar-arterial oxygen
ventilation in the treatment of ARF or specifically ACPO were tension gradient ~2add further credence to its application.
limited. The review articles are discussed in the following sections:
NIPPV in the treatment of ARE CPAP, BiPAP, BiPAP in the Pressures are adjusted according to clinical response and patient
treatment of hypercapnic respiratory failure, BiPAP in the tolerance. In patients with ACPO, pressures of approximately 10-
treatment of hypoxaemic respiratory failure, critique of current 12.5cmH20 are most commonly used, having demonstrated
literature and a discussion of the rationale for treatment of ACPO significant reductions in the need for intubation lz.
with BiPAE
In patients with congestive heart failure, CPAP can improve
haemodynamics by reducing preload and afterload 4. L2, as positive
NIPPV in the treatment of ARF
pressure reduces venous return to the left ventricle. In patients
Traditionally, management of patients presenting to the ED in with normal left ventricular function, and hence those sensitive to
either severe hypoxaemic (type 1) or hypercapnic (type 2) changes in preload, a subsequent reduction in cardiac output may
respiratory failure has involved invasive mechanical ventilation via occur 4. However, in patients with impaired left ventricular
endotracheal intubation 6. Treatment is directed toward correcting function, a reduction in preload may actually improve cardiac
the pathophysiology of ARF, reducing work of breathing and function. As positive pressure is transmitted to the left ventricle
ameliorating dyspnoea. Concomitant pharmacological causing a reduction in transmural pressure and afterload, left
intervention is focused on correcting causative conditions ventricular performance and hence stroke volume may improve 4.12.
preceding ARF 1. Despite the emergent requisite for such
management regimes, intubation and ventilation is associated with Additional functional benefits correlate to the effects of positive
end expiratory pressure (PEEP) in mechanical ventilation delivered
numerous adverse outcomes, including both infectious and non-
to non-spontaneously breathing patients. The application of
infectious complications 8.
CPAP/PEEP promotes the ability to counteract intrinsic or
The endotracheaI intubation process entails risk of traumatic tissue dynamic PEEP, reducing lung hyperinflation and assisting in passive
injury to the pharynx, larynx and trachea v The risk of exhalation of respiratory gases ~.
endotracheal tube cuff induced tracheal ischaemia has also been
noted 1. The significance of associated loss to anatomical barriers of
BiPAP
infection through such invasive methods is related to ventilator- BiPAP is an adaptation of the standard delivery of CPAP
associated nosocomial infections and subsequently accounts for ventilation. It provides the physiological advantages of CPAP
relatively higher mortality rates 2, 4. ~. ~o. H. Additional consequences through the application of an expiratory positive airway pressure
associatecl with intubation include loss of speech and oral intake (EPAP). The addition of an inspiratory positive airway pressure
and the inability to expectorate and voluntarily clear the airways. (IPAP) intermittently delivers an additional level of positive airway
pressure 2. A higher flow rate is provided during initial inspiration,
Furthermore, patient-ventilator asynchrony often occurs secondary thereby actively assisting spontaneous ventilation. Positive
to patient discomfort and/or agitation. In an attempt to improve pressure support (PPS) is therefore provided through the difference
both patient comfort and enhance the efficacy of ventilatory between the IPAP and EPAP.
support, sedation is frequently required. This, however, often
The effects of EPAP/CPAP in alveolar recruitment are
complicates the weaning process 4, lengthening the time in which
predominantly achieved by raising intra-alveolar pressures. This
patients require ventilatory support and contributes towards improves recruitment of atelectatic alveoli, increases lung
associated costs of intensive care. functional residual capacity 3 and improves the diffusion of oxygen
into pulmonary capillaries. As per the effects of CPAP ventilation,
NIPPV involves the provision of ventilatory support to the
EPAP also contributes toward the redistribution of lung water ~,
spontaneously breathing patient in the absence of endotracheal
increasing the alveolar surface area available for participation in
intubation H. It involves the delivery of a positive pressure through
gaseous exchange.
either a full facial or nasal mask to the upper airways, thus actively
assisting respiration through augmentation of alveolar ventilation 1. BiPAP, as with any form of NIPPV, cannot be applied without
NIPPV is therefore used as an alternative method of treatment for consideration given to adverse side effects or the potential
patients in ARF whilst avoiding the complications associated with development of evolving contraindications (rare but certainly
endotracheal intubation and invasive ventilation ~. relevant to safe practice). Importantly, BiPAP is limited in use by

Volume 15 Number2 May2002 52

 AK
Australian Critical Care

specific patient criteria. Specific patient criteria and practical Figure 1. Comparison of tidal volumes with variable positive
considerations for the application of BiPAP are included in Table 1. airway pressures for CPAP versus BiPAP ventilation
(adapted from lr).
The respiratory effort of patients in ARF is typically rapid and
shallow. As such, much of the tidal volume is wasted as dead space
P pressure (cmH20)
ventilation, potentially propagating retention of carbon dioxide Vol volume (mls)
and development of respiratory acidosis '. The addition of PPS,
achieved through the application of IPAP, assists the patient's own
vendlatory effort by producing a positive pressure during initial a) CPAP ventilation.
inspiration. Theoretically, the inspiratory assistance afforded by
BiPAP ventilation promotes inhibition of the diaphragm ~5 and P (cmH20)
superior respiratory muscle rest ]6. The resultant effect is a reduction
in inspiratory effort (or work of breathing) required by an already
fatigued patient whilst simultaneously enhancing tidal volume and
gaseous exchange.
10 ~ ^ A /%__
The ventilator,/assistance afforded by BiPAP compared to CPAP
ventilation, in order to enhance tidal volume whilst supporting a
reduction in work of breathing, is demonstrated in Figure 1. 0t ..... i i i i i I i i i f i I i i i i i 2/

12 18 4

Table 1. Practical considerations in the application of BiPAP

ventilation (adapted from z, s....... 4). Vol (ml)

Selection criteria , , :: 1500-

-. Spontane0usly.@;eathihgpatient : 1000-
Adequate lev~l0f o0nSci0usness to sustain a i r w a y patency
500-
• :Ability to Clea."r,.ow.n.":&itway of secretions:
• C o o p e r a t i v e ~ i i e ' n t "": : 0-
•, Ability to obtain: ade~l~ate m a s k s e a l
• H a e m o d y n a m i ~ S~biiity -500 .... I i i n n n I i i i i i I n i n n , I

6 12 18 24
Advantages CPAP ventilation
• Reduced cost in intensive care required CPAP = 8cmH20. Tidal volumes are dependant upon patient's own work of
• Reduced length of time requ r ng ventilatory support breathing•

Avoids incidence of infection associated with endotracheal

intubati0n . .. ; : b) BiPAP ventilation.
PreservatiOn of speech, swallow, abil~[Link].6iear airway s
Sedation rarely indicated or required - -" . ". " ". P (cmH20)

Improved synchrony with ventilator ....

20-
Minimal difficulty in weaning ventilatory support

Potential complications
• Barotrauma ., ' 10
• Haemodynamici,nstabil ty
• Aerophagia: " :( , ,
• Aspiration Of gadtdC contents 0 , , , , , i i i i i i i i l l l ~ l ~ l

• Inadequate d e i ! w r y of ventilatory support requiring

6 12 18 '14
endotracheai ~ntubati6n
Vol (ml)
Contraindications:
• Pneumothorax :::" : 1500-
• Decreased lave Of consciousness (if not due to CO2
1000-
retention) :
• Refract0ry/impending respiratory failure 500-
Cardiac/respiratory arrest
0-
• Any indication for immediate endotracheal intubation
• Excessive respiratory muscle fatigue -500 i ~ i i i I i d 1 a ~ I i i i a i I ~ ~ i t I

• Traumatic cause of respiratory failure 6 12 18 24

'~ Facial trauma
,, Inability to maintain airway patency BiPAP ventilation
• Excessive airway secretions IPAP (15cmH20) - EPAP (6cmH20) = PPS (9cmH20).
• Cardiac arrhythmia with compromised cardiac output Tidal volumes are achieved with reduced work of breathing through the
addition of positive pressure support•

53 Volume 15 Number2 May2002

 Australian Critical Care

A reduction in respiratory rate and diaphragmatic activity is Despite this interest, and what would appear to be theoretical logic,
achievable in proportion to the amount of PPS applied '. there remains persistent controversy and minimal research
dedicated to the specific role of BiPAP in ACPO. In particular, a
Despite the theoretical advantages of BiPAP, there remains study conducted by Mehta and colleagues in 199719 raised serious
controversy over its exact role in the universal treatment of ARE doubts as to the safety of BiPAP in the treatment of pulmonary
Ambiguity pertains to the effectiveness and safety of BiPAP in the oedema. The adverse results of using BiPAP in the treatment of
treatment of hypoxaemic respiratory failure ,a, particularly ACPO. ACPO, as identified in this particular study, have been consistently
Comparatively, there exist numerous reports of the benefits of BiPAP referred to in subsequent literature. Mehta et al. accepted the
in the treatment of hypercapnic respiratory failure 7.9,10.,3.14.,9,2o.
therapeutic actions of CPAP, including increased functional
residual capacity, decreased intrapulmonary shunting, reduced
BiPAP in t h e t r e a t m e n t o f
incidence of atelectasis, improved cardiac output through reduction
hypercapni¢ respiratory failure of left ventricular afterload and reduction in work of breathing
In the instance of acute presentations of COPD, increased airway through improved pulmonary compliance. It was hypothesised that
resistance causes obstructive expiratory flow with resultant BiPAP would result in a more rapid recovery from pulmonary
pulmonary hyperinflation. The subsequent oxygen-cost of oedema secondary to the role of EPAP and the added effect of
breathing is exacerbated by respiratory muscle fatigue, predisposing active inspiratory assistance. It was also advocated that BiPAP
patients to hypercapnia and acidosis. Ventilatory support, would be more successful than CPAP in the avoidance of
traditionally via means of endotracheal intubation and mechanical intubation.
ventilation, is required to alleviate respiratory muscle fatigue 7.
The study's objective was to evaluate whether BiPAP ventilation
However, improved gaseous exchange and reduced incidence of
effectively improved ventilation, acidaemia and dyspnea more
intubation has been demonstrated with NIPPV via delivery of
rapidly than CPAP in patients with ACPO. The study was a
positive inspiratory pressure to patients with acute exacerbations of
randomised, controlled trial of 27 patients who presented to the ED
COPD 2,.
in acute pulmonary oedema. There was an even distribution of
A recent me,a-analysis examining the effects of NIPPV 6 proposed subjects by randomisation into either the BiPAP or CPAP group
that its efficacy was in fact limited to patients in whom the specific (14 & 13 respectively), and all patients received standardised
cause of ARF was an exacerbation of COPD. It was identified that pharmacological treatment of pulmonary oedema.
ARF in this population of patients is often due to hypercapnic, All BiPAP subjects received ventilatory support via nasal mask,
type 2 respiratory failure. The me,a-analysis suggested a definitive while the CPAP group used fuli facial masks. Pressure support for
association between treatment of COPD with bi-level ventilation the CPAP group was provided at 10cmHzO, whilst the BiPAP
and beneficial survival rates and a reduction in the need for group received EPAP at 5cmH20 and IPAP at 15cmHzO.
endotracheal intubation 6. The role of BiPAP ventilation in further Comparatively rapid and statistically significant (p<0.05)
decreasing work of breathing has been identified as the improvements in ventilatory and vital sign parameters at 30
fundamental advantage it offers in promoting respiratory muscle minutes (including breathing frequency, heart rate, blood pressure,
rest and hence the capacity to minimise the incidence of and PaCO z concentrations) were achieved in the BiPAP study
hypercapnia and development of respiratory acidosis 4. group ,9.

BiPAP in t h e t r e a t m e n t o f However, the study was prematurely ceased secondary to an

hypoxaemic failure interim analysis of results suggesting a significantly high
incidence of myocardial infarction in the BiPAP patients. This
Patients with ACPO typically have an increase in lung water and
was measured by a rise in the creatinine kinase MB fraction.
airway resistance, reduced lung volumes and poor lung compliance.
Seventy one per cent of patients in the BiPAP treatment group
Collectively these sequelae propagate an increase in work of
revealed retrospective evidence of myocardial infarction,
breathing 4'~2. The provision of non-invasive ventilatory support by
compared to only 31 per cent of the CPAP candidates (p=0.06) ,9.
CPAP has been shown to decrease circulatory distress, significantly
The authors claimed that, upon commencement of the study, the
reduce intrapulmonary shunting and improve oxygenation 12. This
characteristic presentation of patients were similar; age, gender
success of CPAP during the last decade in patients with ACPO has
composition, acuity and initial creatinine kinase concentrations.
prompted examination of the use of BiPAP ventilation in such Severity of respiratory failure was also similar for both groups; for
presentations ~'. respiratory rate, heart rate, arterial blood gases and serum lactate
concentrations. No significant difference in haemodynamic
The ability to further reduce work of breathing theoretically
parameters was recorded between the two groups upon enrolment.
represents the advantages of BiPAP in the treatment of patients
Mean lengths of time spent requiring ventilatory assistance, plus
with hypoxaemic respiratory failure. Whilst the functional
length of stay in the hospital and intensive care unit were similar
advantages of EPAP equate to those provided by CPAP, the ability
for both groups.
to provide PPS through 1PAP is believed to enhance respiratory
muscle rest. BiPAP thus assists the patient in ACPO in three ways; Another notable indication of myocardial infarction involved the
it decreases work of breathing, enhances exchange of both oxygen recording of six BiPAP candidates whose initial
and carbon dioxide and improves cardiac output =. As such, BiPAP electrocardiograph (ECG) revealed ST elevation. Five of these
may be conceptualised as an advanced and alternative form of candidates later revealed evidence of infarction. Interestingly, six
NIPPV. CPAP candidates also had ST elevation on their initial ECG,

Volume 15 Number 2 May 2002 54

 AN
A u s t r a l i a n Critical Care

with only one of these patients showing a creatinine kinase rise Nasal mask ventilation may result in insufflation through the
indicative of infarction. This finding was, however, not mouth with subsequent loss of positive airway pressure ~6. Facial
statistically significant (p=0.08) 19. masks reportedly provide a superior seal2and hence maximise
efficacy of ventilatory support. Indeed, increases in diaphragmatic
The authors 19 specifically noted that the previously mentioned activity from 15-98 per cent have been reported in patients with
achievements of comparatively rapid improvements in ventilatory closed and open mouths, respectively, during treatment with
and vital sign parameters when using BiPAP ventilation could only NIPPV*. Furthermore, if insufficient IPAP is delivered secondary
be clinically acceptable in the absence of significant adverse to circuit leaks, the BiPAP® ventilator will continue to deliver
outcome variables. The notable finding of a higher incidence of higher inspiratory airway pressures secondary to a failure to detect
myocardial infarction in the BiPAP study group negates the the decline in inspiratory flow required to terminate inspiration 11.
otherwise favourable indications of the benefits of BiPAP As noted by Mehta and colleagues, substantial air leaks when using
ventilation. the BiPAP~ system may cause an increase in the duration of
inspiratory time for as long as 3 seconds, thereby increasing
Although this study was unexpectedly and prematurely ceased in inspiratory/expiratory ratios to as much as 3:1 or even 4:119. If tile
view of these results, the findings should not automatically generation of air leaks between patient and interface can result in
disparage the possible role of BiPAP in the treatment of ACPO. extended periods of inspiratory support, it may also be possible that
Larger randomised trials into the effects of bi-level ventilation on use of nasal masks in the BiPAP group influenced myocardial
ACPO were recommended, with particular attention directed perfusion and hence incidence of infarction.
toward the effects of BiPAP on peak airway pressures,
haemodynamics and myocardial infarction rates ~9. There has also been suggestion that the relationship between
reduced cardiac output and higher inspiratory pressures does not
Despite modest attempts to explain the possible causes of such account for the incidence of myocardial infarction in the Mehta
unexpected findings *~, the results have been repeatedly referred to study. Rather, close scrutiny of the baseline characteristics of
by subsequent literature reviews in discussing the limitations of sample subjects reveals that incidence of infarction actually
BiPAP. A n infarction rate of 71 per cent is undeniably excessive. correlates with the randomised characteristics of patients that
However, the findings of this study must be kept in perspective of initially displayed evidence of cardiac ischaemia. In fact, 71 per
its limitations. Methodological and clinical issues of nasal versus cent of the BiPAP candidates and 31 per cent of the CPAP patients
full facial mask, baseline characteristics of subjects, sample size and displayed evidence of ischaemic chest pain upon enrolment into
baseline pressures applied require further examination. the study 4.24.

Mehta and colleagues ~9noted the difficulty in ascertaining exactly Importantly, the issue of initial inspiratory and expiratory airway
when some of the infarctions occurred, suggesting that some of the pressure settings have also been largely ignored by subsequent
myocardial infarctions may have been underway before enrolment literature reviews. Whilst equating the therapeutic advantages of
into the study. They also postulated that bi-level airway pressures EPAP with CPAP in the treatment of hypoxaemic ARF, Mehta and
caused a greater increase in intrathoracic pressures and hence a colleagues specifically hypothesised that the addition of active
decrease in cardiac output. Furthermore, it was noted that in the inspiratory support, as provided by IPAP, would comparatively
improve the physiological effects of ACPO 19. Despite such
event of the BiPAP ® device detecting an airway leak, which is
recognition, however, initial expiratory pressures for the CPAP
common in the application of nasal rather than full facial masks 23,
group (10cmHzO) were greater than those applied to the BiPAP
the inspiration/expiration ratio could possibly have been extended.
group (5cmHiO).
The resultant effect may have lead to extended periods of time
spent in the inspiratory phase 19, thereby extending exposure to If tile effects of EPAP can be equated with the effects of CPAP, a
higher positive airway pressures. difference of 5cmHzO in initial pressures for the two groups may
certainly be significant. If CPAP and EPAP are believed to
A recent study" researching the use of BiPAP in ARF in the ED
contribute toward improved oxygenation, it is possible the BiPAP
identified similar concerns in applying bi-level pressures.
group were potentially disadvantaged by the less aggressive
Specifically, it was proposed that whilst greater inspiratory pressures
approach applied in the expiratory pressures reported. Conceivably
can induce inspiratory muscle rest, higher inspiratory pressures also this aspect of adequate pressure settings may have contributed to
increase intrathoracic pressure, thereby reducing venous return and poorer myocardial perfusion status through inferior attempts at
decreasing myocardial blood flow. It may therefore be that early improvements in oxygenation, rather than the exclusive
lengthening the time spent in the inspiratory phase further addition of inspiratory pressure as provided by bi-level ventilation.
increases the likelihood of extended periods of decreased In studying the haemodynamic effects of BiPAP compared to CPAP
myocardial perfusion. in patients with heart failure, Philip-Joet and colleagues 25
concluded comparative improvements in PaO 2 and PaCO2 in
In recognition of the possible link between high inspiratory airway
patients with or without congestive heart failure when PPS was
pressures and subsequent decreased myocardial perfusion, it is
provided.
possible that perhaps the use of nasal masks increased exposure to
higher inspiratory airway pressures. The initial choice of an Additional concerns relating to sample size are relevant because,
appropriate interface in acute presentations, that is nasal versus full importantly, the results reflected the outcome of only 27 patients.
facial mask, has been questioned in relation to the ultimate success Pang and colleagues is clearly recognised that sample size limits the
of NIPPV~. ability to draw concrete conclusions about the impact on mortality

55 Volume 15 Number 2 May 2002

 Australian Critical Care

or intubation. Mehta and colleagues 19recognised sample size as a controlled design both identified adverse patient outcomes,
possible deficiency in proving validity of results and in this study including a significantly high incidence of myocardial infarction 19
was recorded as not being statistically significant (p=O.06). It was, and a higher mortality rate L In the latter study, the authors
however, noted that the potential implications could not be postulated that the application of BiPAP in the ED deferred
ignored. initiation of tracheal intubation and mechanical ventilation and
hence contributed to poorer patient outcome. The time interval
Importantly, the study did indicate that physiological variables from arrival to the ED until endotracheal intubation was
typical of ACPO could be improved more rapidly with BiPAP considerably longer for those patients who received non-invasive
compared to CPAP, although a disproportionate number of BiPAP versus invasive ventilation, and more patients with longer delays
patients also experienced myocardial infarction. The study should acquired more organ system derangements. However, neither the
not, however, be identified as having proven that treatment of time interval before intubation nor the intubation rate for both
ACPO by BiPAP causes myocardial infarction. As noted by groups of patients is reported as being statistically significant!
Poponick and colleagues 13,subendocardial infarction may well have
been the cause of the presenting pulmonary oedema. It is, however, In the only non-random design study 13, 15 of 16 patients presenting
imperative that the inference is noted with reserved caution. with ACPO were successfully treated with BiPAP. This was the
only other study to report incidence of infarction. Two patients
The comparative infarction rate for the control group, involving a showed retrospective evidence of infarction but were reportedly
retrospective review of non-ventilated patients, was similar (38 per successfully treated with BiPAP ventilation. Both patients had a
cent) to the smaller incidence reported in the CPAP group. The known history of ischaemic heart disease and congestive heart
infarction rate for the control group was also significantly lower failure, and neither showed evidence of cardiac ischaemia prior to
than for the BiPAP candidates (p=0.05) 19. As suggested by the BiPAP ventilation 13.
authors, further research is required with emphasis on effects of bi-
level ventilation on haemodynamics and myocardial infarction There are also further difficulties in assessing the comparative
rates. effects of BiPAP ventilation. This includes variations in airway
pressure settings with varying use of specific ventilatory support
Critique o f c u r r e n t r e s e a r c h systems. Furthermore, the absolute standards used to measure
Despite existing theoretical rationale, there is a lack of research- patient inclusion and exclusion criteria can be difficult to define,
based evidence for the treatment of ACPO with BiPAP. and disparity may invariably lead to unmatched baseline
Notwithstanding references to research studies indicative of characteristics and bias in sample inclusion (Table 3).
favourable outcomes, difficulties in determining the role of BiPAP
in ACPO involve both procedural and methodological issues. As previously discussed, the pressure settings used to evaluate the
Limitations include differences in study design, sample size, actual comparative effects of BiPAP and CPAP in the Mehta study ~ may
types of ventilation compared or tested, type of interface between well have influenced patient outcome. In identifying a higher
ventilator and patient, variations in explanation of patient mortality rate in patients treated with BiPAP, Wood and colleagues8
outcome and the reported incidence of myocardial infarction applied pressures of EPAP 2-4cmH20 and IPAP 8cmH20. This
(Table 2). certainly raises the question of whether inadequate pressure settings
contributed toward poorer patient outcome comparative to other
Inadequate sample size poses problems in the ability to confidently studies.
generalise the effects of BiPAP. Further analysis reveals that sample
size particular to the specific type of ARF studied complicates Importantly, the effects of BiPAP on gaseous exchange are
confirmation of actual evidenced-based effects on patient outcome. dependent upon pressures applied. Incidence of carbon dioxide
Considerable improvements in intubation rates 19 for patients rebreathing, secondary to inadequate exhalation of respiratory gases
receiving NIPPV (7 and 8 per cent for BiPAP and CPAP through the exhalation valve, can reportedly be reduced by
respectively) compared to those receiving non-ventilatory support increasing minimum EPAP 7. The pressure settings used (EPAP
(33 per cent), and significant improvements in clinical status for 10cmH20) in the study by Antonelli and colleagues 14 are thus
NIPPV patients relative to spontaneously breathing patients (93.4 noted with comparative interest. Not only does this represent a
vs 60 per cent, respectively) ~, were reported for both hypoxaemic more aggressive approach in oxygenation, such expiratory pressures
and hypercapnic forms of ARE Considering that different are more likely to actively support exhalation of carbon dioxide.
presentations of ARF are likely to require individual management, Furthermore, it was concluded that BiPAP delivered through a full
the ability to generalise the effects of BiPAP in the treatment of all face mask in patients with severe hypoxaemic ARF was as effective
forms of ARF may be difficult. as mechanical ventilation in improving gaseous exchange when
ventilator pressure settings were similar 14.
Additional variables such as the type of mask used do not appear to
have significantly affected outcome; however, there is a notable Both subjective and objective variations in the descriptions of
absence of comparative studies involving nasal versus full facial inclusion criteria were noted. This exemplifies how bias could
masks. Some studies used either mask dependent upon subjective occur due to a reluctance/inability to initiate intubation in the
principles such as patient comfort or evaluation of adequate seal 10,13, instance of patient deterioration whilst being treated with BiPAR
although incidence was not specifically reported. Only one study identified patients with advanced directives not to
receive endotracheal intubation. In this study 10, two patients who
Study design limitations also influence the ability to correlate the did not tolerate BiPAP were considered ED treatment failures.
effects of BiPAP. Despite favourable patient outcomes for BiPAP in Neither of these patients were intubated secondary to advanced
the majority of reports, two studies that used a randomised directives.

Volume 15 Number 2 May 2002 56

 AN
Australian Critical Care

Table 2. Methods and outcome of studies examining ventilatory assistance in A R E

P o p o n i o k et al. 13 • COPD 30 BiPAP NM & FM • 74% successful 2 patients,

Non-random • COPD/CHF 6 used, with shorter LOS both presenting
Non-controlled • ACPO/CHF 16 incidence • 15 of 16 patients with A C P O
• Pneumonia 3 not specified with A C P O successful
• Muscle w e a k n e s s 2 • 25.9% intubated
• Sleep a p n o e a 1

Antonelli e l al. ~4 Hypoxaemic ARF

Randomised • Pneumonia 5 BiPAP FM • 62% improved PaO2:FiO2 Not reported
Prospective • Trauma 4 within 60 minutes,
• ACPO 7 38% infective complications
• PRF 16
• Pneumonia 4 MV ETT • 47% improved PaO2:FiO~
• Trauma 4 within 60 minutes,
• ACPO 5 66% infective complications
• PRF 19

C e l i k e l et al. ~ • Acute exacerbation 15 PEEP + PPS FM • 93.4% improved Not reported

Randomised COPD 15 No ventilatory Nil • 60% improved
Controlled assistance
Prospective

W o o d et al. 8 • COPD + pneumonia 6 BiPAP NM • 43.8% intubated Not reported

Randomised • C O P D + CHF 5 25% mortality
Controlled • COPD 4
Prospective • COPD + pneumonia 5 N o ventilatory Nil • 45.5% intubated
• C O P D + CHF 3 assistance 0.0% mortality
• COPD 7

Mehta et al. ,9 • ACPO 14 BiPAP NM • 7 % intubated 71%

Randomised 13 CPAP FM • 8 % intubated 31%
Controlled 21 No ventilatory Nil • 33%intubated 38%
assistance

P o l l a c k et al. 10 " CHF 16 BiPAP NM & FM • 86% successful Not reported

Non-controlled • COPD 9 used,
Prospective • COPD+CHF 3 incidence
• Pneumonia :10 not specified
• Status asthmaticus 6
• Other (ARF) 6

* Refer to Table 4 for explanation of improvement in physiological variables or defining characteristics of successful treatment as per individual studies.
ACPO=acute cardiogenic pulmonary oedema ARF=acute respiratory failure COPD=chronic obstructive pulmonary disease
CHF=congestive heart failure CPAP=continuous positive airway pressure ETT=endotracheal tube
FiO2=fraction of inspired oxygen FM=full facial mask MV=mechanical ventilation
NM=nasal mask PaO2=arterial partial pressure oxygen PEEP=positive end expiratory pressure
PPS=positive pressure support PRF=postop respiratory failure VS=ventilatory support

57 Volume 15 Number 2 May 2002

 ,41',,
Australian Critical Care

Table 3. Study variations in pressure settings, patient inclusion and patient exclusion criteria.

P o p o n i c k et a1.13 BiPAP EPAP 4cmH20 • Haemodynamically stable • Obtunded patient

IPAP 8cmH20 (not requiring vasopressors) • Uncooperative or combative
• Alert & cooperative • Lacking gag reflex
• Capable protecting airway • Haemodynamically unstable
• Fatigue (increased BR, use
of accessory muscles
paradoxical breathing,
subjective complaint of tiredness)
• PaCO2>50mmHg with pH<7.30
• PaO2<60mmHg with FIO2>0.5

A n t o n e l l i et al. TM BiPAP EPAP up to 10cmH20 Acute respiratory distress • COPD

until FiQ<0.6 determined by: • Immunosuppressive therapy
PPS increased to • Dyspnoea at rest • Required emergency ETI
achieve TV of • BR>35 • Cardiorespiratory arrest
8-10mls/kg • PaQ2:FiO2 <200 • Severe haemodynamic instability
ETI/MV PEEP 5cmH20 , with supplemental 02 • Encephalopathy
increased to 10cmH20 • Active contraction • ARF secondary to neurologic disease
until FIO2<0.6 accessory muscles • Status asthmaticus
TV 10mls/kg of respiration or • New failure organ s y s t e m s
• Paradoxical abdominal motion • Tracheostomy, facial deformities
• Recent oral, oesophageal,
gastric surgery

Celikel et al. g Non-invasive PEEP 5cmH20 • Known history COPD • Need for urgent ETI due to
pressure PPS 15cmH20 or to • PaCO2>45mmHg respiratory arrest
support achieve TV 5-7mls/kg • pH<7.35 • SBP<90mmHg
ventilation • Evidence respiratory muscle fatigue; • Severe cardiac arrhythmia
BR>22, use accessory muscles, • Abundant secretions
observation of respiratory distress • Myocardial infarction or cardiac arrest
within 3 months of inclusion in study
• Patient refusal

W o o d et al. 8 BiPAP EPAP Evidence ARF with acute onset • Immediate indication for ETI
2-4cmH20 moderate-severe dyspnoea as per: • SBP<90mmHg post
IPAP • BR>25 with one of 500ml fluid bolus
8cmH20 • pH<7.35 • Ventricular arrhythmia
• PaCO2>45mmHg • Upper airway obstruction
• PaO2<55mmHg on room air or facial trauma
• SAO2<90% on room air • Inability to clear airway secretions
• A:a gradient >100mmHg with • Uncooperative patients
supplemental oxygen • Presence tracheostomy tube
• Predetermined patient request
not to receive ETI/MV
• Acute exacerbation asthma
• Pneumothorax, chest wall trauma

Volume 15 Number 2 May 2002 58

 ,4K
Australian Critical Care

Table 4. Variations in criteria for successful treatment by NIPPV, criteria for termination of N I P P V and the need for E T I .

Author Criteria for success of treatment via N I P P V Criteria for termination NIPPV and need for ETI

Poponick et al. TM • Improvement pH, PaCO2 & PaO2 in 30 minute trial • Clinical appearance
• Stabilisation/decrease HR & BR - Change in mental status
• Decreased accessory muscle use • Post-trial ABG data demonstrating continued
• Subjective decrease dyspnoea hypoxaemia/worsening acidosis

Antonelli et al. 14 Maintenance of the following post removal • Failure to maintain PaO2>65mmHg on FIO2>0.6
' of ventilatory support: • Development conditions requiring airway protection
o BR<30 (for example, coma or seizures)
• PaO2>75mmHg with FiO2 of 0.5 • Copious tracheal secretions
• Maintenance PaO2:FiO2>200, • Haemodynamic/electrocardiographic instability
or ratio of >100 from basetine • Patient intolerance to face mask
• Frequency of complications including
pneumonia, sepsis, & sinusitis
• Duration ventilatory support
• Length of stay in ICU
• Mortality

Celikel et al. 9 • Avoidance ETI • Need for urgent ETI

• Haemodynamic instability/severe cardiac arrhythmia
• Severe agitation
• Convulsion
• Abundant secretions
• Patient request for cessation NIPPV

Wood et al. B • Avoidance ETI/MV • Respiratory arrest

• Hospital mortality rates Respiratory pause with LOC
• Required ICU admission Psychomotor agitation
• Hospital LOS HR<50 with decreased mentation
• Duration MV Haemodynamic instability (SBP<70mmHg)
• Incidence organ failure BR>35
pH<7.30
• PaO2<45mmHg with supplemental 02

Mehta et a1.19 • SAO2>90% with _<2L/min 02 • Discretion ED physician based on clinical/ABG data
• BR<24 • Unrelenting respiratory distress
• Improvement PaCO2 maintained post removal NIPPV • Inability to synchronise with ventilator
• Avoidance ETI/MV • Deterioration vital signs with increased BR or HR
• Duration of ventilatory support or significant haemodynamic compromise
• LOS ICU • PaO2<60mmHg with supplemental oxygen
• Mortality • PaCO2 increased by 5mmHg from presentation

Pollack et al. TM • Increase PaO2 or decrease PaCO2 • Apnoea

• Improvement HR & BR • Patients requiring airway protection
• Avoidance ETI/MV

ABG=arterial blood gas BR=breath rate per minute ED=emergency department

ETl=endotracheal intubation FiO2=fraction of inspired oxygen HR=heart rate beats per minute
ICU=intensive care unit LOS=length of stay LOC=loss of consciousness
MV=mechanicaI ventilation NlPPV=non-invasive positive pressure ventilation PaCO2=artedal partial pressure carbon dioxide
PaO2=arterial partial pressure oxygen ROS=rate of survival SaO2=arterial oxygen saturation
SBP=systolic blood pressure

Volume 15 Number 2 May 2002 60

 A u s t r a l i a n Critical Care

experience of medical and nursing staff in the delivery of adequate simple and endotracheal intubation should be initiated as the
ventilatory support, issues of appropriate monitoring, and the need definitive management strategy.
for clear guidelines for cessation of BiPAP and subsequent
endotracheal intubation. Concern related to ethical considerations Additional variables affecting the success of BiPAP also include the
and intensive nursing time required has also been noted ~6.27. experience of relevant operators and prescribers 28.30. Considering
the existing lack of decisive indicators and established standards for
In recognising the rationale of BiPAP in the treatment of ARE initiation of BiPAP, including controversy over which particular
Poponick and colleagues 13 attempted to identify early patient forms of ARF benefit from such therapy, it is not surprising that
characteristics that predicted its success and the appropriate treatment prescription varies. Subsequently, issues of adequate
duration of treatment before considering intubation. After medical and nursing education are imperative.
analysing multiple variables, the authors concluded that an
improvement in baseline pH and PaCO2 within 30 minutes Considering the role BiPAP plays in resting fatigued respiratory
remained the best predictor of success. However, the ability to muscles and improving oxygenation, inadequate manipulation of
predict which patients would be successfully treated with BiPAP pressure settings may contribute to detrimental outcomes and even
remained difficult, hnportantly, patients with congestive heart rapid patient deterioration. Inspiratory support must be matched to
failure in the setting of ARF were more likely to have success with patient demand. In the instance of insufficient pressure support, the
bi-level ventilation because of the ability to enhance tidal volumes patient will, in effect, 'pull' against the ventilator, causing patient-
and stabilise gaseous exchange. It was suggested that a short trial of ventilator asynchrony, increasing work of breathing and decreasing
BiPAP be appropriately initiated in the absence of definitive the efficacy of ventilatory support. Excessive PPS, however, may
decisions regarding intubation. cause considerable patient discomfort, impede expiration, precipitate
patient-ventilator asynchrony and predispose patients to incidence of
The ability to predict the duration of effective trial treatments of
barotrauma and haemodynamic instability 11.
BiPAP has, however, remained somewhat elusive. A 30 minute
trial of BiPAP has been suggested as the duration of time in which In an analysis of appropriate prescription of NIPPV, Sinuff and
the benefits of treatment should be achieved ,5. Similarly, colleagues 2sfound a significant number of patents receiving BiPAP
significant reductions in respiratory rate, blood pressure, heart rate were not specifically prescribed a particular ventilatory therapy and
and gaseous exchange ,9 have been reported in the same duration of that, for patients with existing orders, the majority were made by
time whilst using BiPAP ventilation in the treatment of ACPO. junior medical officers. Investigations regarding appropriate
Comparative treatment of ACPO with CPAP ventilation included monitoring revealed that cardiorespiratory monitoring was not
only a reduction in breath rate ~9 actually prescribed by physicians, although in 93 per cent of cases
nursing staff had implemented appropriate monitoring 28. Such
Other reports have suggested significant improvement should be
findings indicate that whilst physicians may well oversee the care of
evident within 60 minutes of treatment 2s, whilst a concurrent
patients, it is primarily nursing staff that not only initiate
improvement in exchange of oxygen and carbon dioxide and an
ventilatory support but also ensure the application of essential
increase in pH should be evident within 1-2 hours of ventilatory
monitoring. It is also feasible that nurses, rather than an exclusive
support1. It therefore seems important that extended periods of
physician prescription, are predominantly responsible in adjusting
time do not lapse before patient status directs definitive patient
ventilatory parameters according to physiological responses and
management. Furthermore, it would appear ventilatory support
patient experiences.
from BiPAP is at least appropriate in the absence of definitive
decisions to intubate patients presenting in ARE Importantly, the use of BiPAP does not necessarily equate with a
reduction in required nursing care. Upon application of BiPAP,
However, specific universally agreed indications for the use of
intense nurse-patient interaction is imperative and advanced
BiPAP in patients with ARF remains lacking in the literature. In
observation and communication skills are rnandatory. In order to
fairness, it is recognised that the difficulty in identifying those
ensure patient-ventilator synchrony and effective compliance with
candidates most likely to hnprove from its application in the ED is
ventilatory support, simultaneous analysis of immediate
often limited by immediate accessibility to defining indicators of
physiological variables, minimisation of air leaks through mask
ARF, such as the degree of acidosis. Resource difficulties such as
adjustment and adequate patient explanation and assurance are
available personnel or initial concentration on the primary patient
required. Compared to mechanical ventilation in intubated
survey can make the immediate collection of arterial blood gases
patients, initiation of BiPAP has been reported as being more
impractical. Similarly, blood gas abnormalities are rarely
nurse-labour intensive in its initial stages 26.
considered in isolation for patients presenting with ARE
In recognition of this important workload factor, Plant and
Suggestion that success of NIPPV is higher amongst less severe
acidotic patients has been supported by reports that a pH less than colleagues 3~endeavoured to identify the actual increase in nursing
7.26 indicates an extremely poor prognosis in patients with acute time required when caring for patients receiving NIPPV. The
exacerbations of COPD 29. It is therefore plausible that a results identified a mean increase in additional nursing time of only
correlation exits between the timely application of BiPAP and 26 minutes within the first 8 hours upon admission to a general
success in avoiding endotracheal intubation. respiratory ward, although the authors considered that results
would presumably be very different in the emergency setting with
In summary, the earlier BiPAP is implemented, the more likely its the presentation of severely acidotic ARF patients. Additional
potential benefits are to be realised. In the event that insufficient concerns were identified in relation to the ability of wards with low
respiratory muscle rest is achieved, and subsequent escalating nurse-patient ratios to adequately care for patients receiving any
metabolic derangements develop, removal of BiPAP therapy is form of NIPPV 3,.

61 Volume 15 Number 2 M a y 2002

 AN
Australian Critical Care

level versus continuous positive airway pressure in acute pulmonary 26. Kaminski J & Kaplan PD. The role of non-invasive positive pressure
oedema. Critical Care Medicine 1997; 25(4):620-628. ventilation in the emergency department. Topics in Emergency
20. Miletin MS, Detsky AS, Lapinsky SE & Mehta S. Non-invasive Medicine 1999; 21(4):68-73.
ventilation in acute respiratory failure. Intensive Care Medicine 27. Evans TW. International consensus conferences in intensive care
2000; (26):242-245. medicine: non-invasive positive pressure ventilation in acute
21. Brochard L e t al. Reversal of acute exacerbations of chronic respiratory failure. Intensive Care Medicine 2001; 27(1):166-78.
obstructive lung disease by inspiramry assistance with a face mask. 28. Sinuff T, Cook D, Randall J & Allen C. Noninvasive positive-
The New England Journal of Medicine 1990; 323 (22): 1523-1529. pressure ventilation: a utilization review of use in a teaching hospital.
22. Sacchetti AD & Harris RH. Acute cardiogenic pulmonary oedema: Canadian Medical Association Journal 2000; 163(8):969-973.
What's the latest in emergency treatment? Postgraduate Medicine
29. Doherty MJ & Greenstone MA. Non-invasive ventilation in acute
1998; 103(2):145-166.
exacerbations of chronic obstructive pulmonary disease (COPD): who
23. Cordova FC & Croner GJ. Using NPPV to manage respiratory is eligible? Care of the Critically I1l 2000; 16(4):126, 128, 130.
failure, part 1. Journal of Respiratory Diseases 2000; 21(5):342-344,
30. Raynolds JE. Non-invasive ventilation for acute respiratory failure.
347-348.
Joumal of Eraergency Medicine 1997; 23(6):608-610.
24. Gust R & Bohrer H. Changes in cardiac output do not explain the
higher rate of myocardial infarction associated with the use of bi-level 31. Plant PK, Owen JL & Elliot MW. Early use of non-invasive
compared with continuous positive airway pressure. Critical Care ventilation for acute exacerbations of chronic obstructive pulmonary
Medicine 1998; 26(2):415-416. disease on general respiratory wards: a multicenter randomised
controlled trial. The Lancet 2000; 355(9219):1931-1935.
25. Philip-Joet FF, Paganelli FF, Dutau HL & Saadjian AY. Hemodynamic
effects of bi-level nasal positive airway pressure ventilation in patients 32. Crausman RS. The ethics of bi-level positive airway pressure.
with heart failure. Respiration 1999; 66(2):136-143. CHEST 1998; 113(1):258. •

Chest x-ray quiz

Answer and discussion
The left hemidiaphragm is ruptured as noted by the white
curved density On the posterior to anterior view (arrowed).
Rupture of the diaphragm causes herniation of abdominal
contents, compressing the left lung and possibly the
mediastinum. It is therefore the stomach or bowel that causes
the curved shadow. The lateral view and a schematic
representation (of a PA view) is also included to demonstrate
this injury. There is also an area of consolidation in the left
lower zone (arrowed on PA and lateral view).

For question, turn to page 49 of this issue.

63 Volume 15 Number2 May2002