Guideline: Bi-level positive airway pressure (BPAP) devices

• Appropriate for patients with obstructive sleep apnea (OSA) who have failed continuous positive airway pressure (CPAP)/auto-titrating positive airway pressure (APAP) or require supplemental ventilatory support due to a hypoventilation syndrome

BPAP (with back-up rate feature)

• Appropriate for patients with established central sleep apnea (CSA) diagnosed by an in-lab sleep study demonstrating all of the following:
  1. OSA has been excluded or treated
  2. Oxygen saturation level is 88% or less for at least five (5) continuous minutes while the patient breathes his/her usual fraction of inspired oxygen (FiO₂) OR the patient demonstrates Cheyne-Stokes respiration for five (5) continuous minutes with oxygen saturation falling to 88% or less at least once during that 5 minute interval
  3. A titration study (split-night or whole-night) has demonstrated significant improvement of sleep-related hypoventilation adjusted to the settings that will be prescribed for home use (while breathing the individual's usual FiO₂)

BPAP (with or without back-up rate feature)

• Appropriate in the management of patients with severe chronic obstructive pulmonary disease (COPD) demonstrating either of the following:
  1. Partial pressure of arterial carbon dioxide (PaCO₂) measured by arterial blood gas drawn while the patient is awake and breathing his/her usual FiO₂ is 45 mmHg or greater; OR
  2. Sleep oximetry demonstrates oxygen saturation of 88% or less for at least five continuous minutes while the patient breathes oxygen at 2 L per minute or his/her usual FiO₂ (whichever is higher)

BPAP (with or without back-up rate feature)

• Appropriate in the management of patients with certain restrictive thoracic disorders when both a and b below are true:
  1. The patient has an established diagnosis of a progressive neuromuscular disease (e.g., amyotrophic lateral sclerosis [ALS]) OR a severe thoracic cage abnormality; AND
  2. One of the following statements is true:
     • PaCO₂ measured by arterial blood gas drawn while the patient is awake and breathing his/her usual FiO₂ is 45 mmHg or greater.
     • Sleep oximetry demonstrates oxygen saturation of 88% or less for at least five continuous minutes while the patient breathes his/her usual FiO₂
     • Maximal inspiratory pressure is less than 60 cm H₂O or forced vital capacity is less than 50% of predicted (applies to patients with progressive neuromuscular disease only)

Ongoing Treatment with BPAP

Ongoing treatment is indicated for patients who demonstrate compliance with therapy. Demonstration of compliance is required every 90 days for the first year of treatment and annually thereafter. Compliance is defined as:

1. Use of the BPAP device for greater than or equal to four (4) hours per night on 70% of nights during a consecutive thirty (30) day period within the preceding 90 days; OR
2. There is clinical evidence submitted by the treating provider that demonstrates continued clinical benefit from use of the positive airway pressure device.