4.8: Initiation and Titration of NIV/BiPAP Settings — Read

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Initiating non-invasive ventilation is very similar to how you approach setting up PSV for a spontaneously breathing patient. There are three main settings that need to be adjusted as well as one additional “back-up” setting. First, you will set the oxygen delivery (FiO₂), a distending pressure to help recruit alveoli (EPAP), and a high pressure to augment the patient’s normal breath (IPAP). The back-up setting is a basic $A simplistic black and white illustration of a light bulb symbolizing an idea or inspiration.$ (remember, this setting does not replace the patient spontaneously breathing).

Therefore, the settings to be set for NIV are:

FiO₂
EPAP pressure (similar to PEEP)
IPAP pressure ( $A simple black silhouette of a cat sitting upright, with a tail curled around its body.$ Pressure, similar to pressure support)
$A simplistic black and white illustration of a light bulb symbolizing an idea or inspiration.$

These settings will be discussed in detail below.

FiO₂

FiO₂ is mandatory to set and should be titrated based on what the patient needed before non-invasive application. If on high oxygen, start FiO₂ at $A simple black silhouette of a cat sitting upright.$ and then wean to SpO₂. If the patient does not require a lot of oxygen, starting at $Black silhouette of a cactus with various protruding spikes on a white background.$ and weaning within a few minutes to target $A stylized black silhouette of a person raising their arms, symbolizing victory or celebration.$ is ideal.

EPAP

EPAP pressure is similar to PEEP. It is the distending pressure that helps recruit alveoli and help with oxygenation. Where it differs from invasive ventilation is using an interface of a face mask instead of intubating and sealing the lungs to a ventilator. The normal pleural pressures that exist with spontaneously breathing patients are still present (see the discussion of lung pressures in Chapter 1). This means that the distending pressures of EPAP can be lower than the minimum PEEP you must set. EPAP settings are usually started from $A simple black outline of a smartphone with a blank screen and rounded edges.$ .

IPAP

IPAP is the high pressure NIV will cycle up to when the patient initiates a breath. The difference between the EPAP and IPAP is the delta pressure or change in pressure. The change in pressure is the same as a pressure support or additional pressure given to help augment a person’s breath. Think of the change in pressure between the EPAP and the IPAP ( $A simple black silhouette of a cat sitting upright, with a tail curled around its body.$ pressure) as the push to get up to that high level. This is identical to the Pressure Support in PSV but described a slightly different way in NIV. Think back to the waveform and mountain analogy

Diagram illustrating lung pressure dynamics with peaks for airway pressure, volume of air, and inspiratory time. — Figure 4.8.1: “Mountain Analogy Infographic” by Amanda Robinson, CC BY-SA 4.0

If the difference between the EPAP and IPAP is bigger, that is a larger push of pressure to get to the higher level.

Examples

Example A:

\[\text{EPAP }6\text{ and IPAP }10\xrightarrow{}{} \Delta\frac{P}{PS}\text{ of }4\]

This is a Pressure Support of $Simple black silhouette of a house with a chimney and a pitched roof.$ .

Example B:

\[\text{EPAP }6\text{ and IPAP }12\xrightarrow{}{} \Delta\frac{P}{PS}\text{ of }6\]

This is a Pressure Support of $A simplistic black outline of a mountain range with a sun rising behind it.$ .

In Example B, this is a higher support, or “push,” to give the patient a bigger assist for a larger tidal volume.

IPAP is usually set $A simple line drawing of a cat's head with pointed ears and whiskers.$ above the EPAP and then adjusted to make sure the patient is taking adequate tidal volumes. Increase the IPAP to help the patient take bigger breaths or if they need more support due to increased work of breathing (WOB).

Two words of caution on pressures…

EPAP and IPAP can be increased higher than these initial ranges as needed based on the patient—namely their WOB and issues with CO₂ and oxygen. Pressures should be started lower first and then adjusted after watching the patient for about 30 minutes and checking the effect with ABGs and overall WOB. Don’t start higher than these levels unless directed by a physician or a practitioner experienced with NIV.

Keep in mind as well: the higher the pressures that are used, the tighter the patient’s mask needs to be. A tight mask means additional pressure that is being pushed into your patient’s face and may mean that NIV is not tolerated for a conscious patient. Pressures should be initiated on the lower side and increased as needed over time to promote patient comfort and decrease the risk of failure of therapy due to patient’s refusal to wear the mask. Staying within these starting ranges with slow increases over time will help promote patient tolerance.

\[RR\]

When setting up a patient on NIV, the best guide for choosing your initial numbers originates in the reason the patient would benefit from NIV. As stated earlier, patients usually fall into two categories:

difficulty oxygenating/requiring lung recruitment
or
high CO₂ or hypercapnia/increased WOB.

Patients needing lung recruitment or help with oxygenating will benefit from higher EPAPs and not as large of a $A simple black silhouette of a tree with a curved trunk and full, leafy canopy.$ —resulting in a lower IPAP setting. Patients with high CO₂/increased WOB do not need as much distending pressure (EPAP), but need their IPAPs set higher to ensure a larger $A simple black silhouette of a tree with a curved trunk and full, leafy canopy.$ to help augment their normal tidal volume.

Occasionally, you may have a patient that is a combination of the two situations. These patients will require a higher EPAP as well as a high IPAP with a large $An abstract silhouette of a cat with a curled tail.$ .

Let’s break it down in this table, which shows recommended initial settings according to the type of patient you are dealing with:

Table 4.8.1 NIV Recommended Initial Settings
Type of Patient	Setting Starting Point
Type of Patient	EPAP	IPAP	\[{\color{white}{RR}}\]	FiO₂	Charting Notation
Type 1: Needs oxygenation help and distending pressure	$A simple black silhouette of a light bulb, symbolizing ideas or inspiration.$	$A stylized black and white illustration of a cat.$	$A stylized black and white illustration of a cat.$	$A simple black outline of a pencil with a sharpened tip pointed upward.$	$A simple black silhouette of a cat with its tail curved upward.$ $A simple black silhouette of a cat with an arched back, resembling a playful or defensive posture.$
Type 2: Needs help clearing CO₂ or with increased WOB	$A simple black silhouette of a coffee cup with steam rising from it.$	$A simple black silhouette of a question mark on a white background.$	$A simple black outline of a fish, depicting its body and fins in a stylized manner.$	$A simplified illustration of a person sitting on a chair with a laptop, suggesting a workspace environment.$	$A simplistic black silhouette of a person with wavy hair, sitting cross-legged and working on a laptop.$ $A simple black icon of a shopping cart, facing right, on a white background.$
Type 3: Combo of type 1 and type 2	$A simple black silhouette of a light bulb, representing an idea or concept.$	$An abstract geometric design featuring interconnected shapes and lines.$	$A simple black outline of a fish, depicting its body and fins in a stylized manner.$	$A simple black outline of a pencil with a sharpened tip pointed upward.$	$A simple black silhouette of a person sitting cross-legged in a meditative pose.$ $A simple black outline of a bicycle icon, featuring two wheels and a frame.$

If you are confused, just remember that EPAP helps those lung “balloons” from deflating fully, and that increasing that low pressure might help splint open a few more of the alveoli. A pressure increase will also help push oxygen across the alveolar-capillary membrane. Remember PEEP helping like wringing out a towel? EPAP does the same thing. IPAP is the high pressure the mode will cycle up to. The difference between the EPAP and the IPAP is going to be the amount of support or help to assist with increased $A minimalist line drawing of a dolphin jumping over a wave.$ and also a push to augment the patient’s breath to get rid of more CO₂.

“Initiation and Titration of NIV/BiPAP Settings” from Basic Principles of Mechanical Ventilation by Melody Bishop, © Sault College is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License, except where otherwise noted.

This page titled 4.8: Initiation and Titration of NIV/BiPAP Settings was last modified on Fri, 16 Oct 2026 18:13:16 GMT and is shared under a CC BY-NC-SA 4.0 license and was authored, remixed, and/or curated by Yvonne Drasovean via source content that was edited to the style and standards of the LibreTexts platform.

Contents

Text

FiO2

EPAP

IPAP

Examples

FiO₂