Critical Care Medicine-Neurologic Disorders>>>>>Mechanical Ventilation
Question 9#

A 68-year-old man with chronic obstructive pulmonary disease (FEV1 30% predicted, on 3 L home O2 ) presents to the emergency department with increased dyspnea for the past 3 days requiring a frequent albuterol-ipratropium nebulizer use at home. He is found to have labored breathing and his initial ABG shows pH 7.27 with a PCO2 90 mm Hg. His chest radiograph demonstrates no infiltrate but some increased interstitial markings consistent with volume overload. He is diagnosed with an acute exacerbation of chronic obstructive pulmonary disease and possible cardiogenic pulmonary edema and started on bronchodilators and given a dose of furosemide. On reevaluation, he is somnolent but arousable to sternal rub and is placed on bilevel positive airway pressure ventilation (BiPAP).

Which of the following is most true regarding use of BiPAP in this patient?

A. Treatment of patients like this with BiPAP is associated with increased mortality because it delays intubation
B. Treatment with BiPAP is associated with longer hospital length of stay
C. Coincident acute cardiogenic pulmonary edema is a relative contraindication to BiPAP
D. BiPAP is more likely to improve outcomes in patients with asthma than in this patient
E. His altered mental status is a relative contraindication to treatment with BiPAP

Correct Answer is E


Correct Answer: E

Noninvasive positive pressure ventilation may reduce the rates of intubation, reduce the time to clinical improvement, and reduce mortality in patients with an acute exacerbation of chronic obstructive pulmonary disease with hypercarbia (answers A and B are incorrect). In patients with acute cardiogenic pulmonary edema, noninvasive positive pressure ventilation is associated with a decreased rate of intubation and decreased time to improvement in symptoms (answer C is incorrect).

Relative contraindications to BiPAP include significant secretions, altered mental status, and a patient’s inability to protect their airway (answer E is correct). The data for use of BiPAP in patients with asthma are inconclusive and much less robust than data supporting use in chronic obstructive pulmonary disease (answer D is incorrect).


  1. Osadnik CR, Tee VS, Carson-Chahhoud KV, et al. Non-invasive ventilation for the management of acute hypercapnic respiratory failure due to exacerbation of chronic obstructive pulmonary disease (Review). Cochrane Database Syst Rev. 2017;(7):CD00410.
  2. Gray A, Goodacre S, Newby DE, et al. Noninvasive ventilation in acute cardiogenic pulmonary edema. N Engl J Med. 2008;359(2):142-151.