Misunderstood: CPAP, BiPAP, and NIV in Long-Term Care

CPAP and BiPAP are staples in respiratory care, commonly used for conditions like obstructive sleep apnea (OSA) and chronic hypercapnia in COPD. While their development represents significant progress in managing respiratory failure, there’s often a disconnect in how these devices are understood and used in nursing homes.

Many facilities assume these therapies are primarily for OSA, but in reality, many nursing home patients use CPAP or BiPAP to manage chronic hypercapnia, often linked to other conditions. This misunderstanding can lead to poor compliance, limiting the benefits these therapies provide.

Let’s dive into the history of CPAP and BiPAP, the challenges in their use, and why understanding their purpose is key to improving outcomes.

The Evolution and Impact of CPAP and BiPAP Therapy

The invention of Continuous Positive Airway Pressure (CPAP) in the 1980s revolutionized sleep medicine by providing a non-invasive solution for obstructive sleep apnea (OSA). This innovation paved the way for Bilevel Positive Airway Pressure (BiPAP), introduced in 1989, which added dual pressure settings—higher during inhalation (IPAP) and lower during exhalation (EPAP)—to improve comfort and reduce respiratory muscle strain.

Before these therapies, patients with chronic hypercapnia and respiratory failure often faced frequent hospitalizations, reliance on invasive mechanical ventilation, and poor survival rates. Since the introduction of CPAP and BiPAP, hospitalizations and intubation rates have dropped, while patients now experience improved survival, independence, and quality of life. These therapies have transformed the management of chronic respiratory conditions, reducing the need for invasive care and minimizing healthcare costs.

The Misunderstood Role of NIV in Nursing Homes

Even though NIV technologies have been around for decades, there’s still a disconnect in nursing homes when it comes to understanding the true purpose of these therapies.

What Many Believe

Many nursing home staff and providers assume that CPAP and BiPAP are prescribed for OSA. Given CPAP’s origins in sleep medicine, it’s easy to see why this assumption persists.

The Reality

In long-term care settings, a significant number of patients on CPAP or BiPAP are not using it for OSA. Instead, these devices are critical for managing chronic hypercapnia, which often leads to chronic respiratory failure. Key contributing conditions include:

• COPD
• Obesity hypoventilation syndrome
• Neuromuscular respiratory failure

Why It Matters

This misidentification leads to a critical gap in care: low compliance.

• NIV devices are notoriously underused, with compliance rates often below 50%.
• Nursing home staff may not prioritize therapy adherence if they don’t understand its importance in preventing chronic respiratory failure and stabilizing patients with hypercapnia.
• Providers are less likely to address compliance issues without clarity on the underlying condition.

Consequences of Low Compliance

Non-compliance with CPAP or BiPAP can have serious consequences for hypercapnic patients:

• Worsening CO? Retention: Leading to episodes of respiratory failure, cognitive impairment, and cardiac strain.
• Frequent Hospitalizations: Hypercapnic respiratory failure is a common cause of readmission.
• Increased Mortality: Untreated chronic hypercapnia and the associated respiratory failure significantly raise the risk of death.

For OSA patients, non-compliance often results in poor sleep and daytime fatigue. But for hypercapnic patients, the stakes are higher—non-adherence can exacerbate respiratory failure and be life-threatening.

Identifying the Real Reason for NIV Therapy

To bridge this gap, nursing homes need to:

1. Clarify the Diagnosis: Understand whether the patient is using NIV for OSA, chronic hypercapnia, or another condition.
2. Educate Staff: Ensure caregivers know that CPAP and BiPAP are often vital for preventing chronic respiratory failure and managing chronic conditions, not just sleep apnea.
3. Engage Providers: Work with respiratory therapists and physicians to emphasize compliance and troubleshoot barriers.
4. Monitor Compliance: Use data from modern NIV devices, which track usage and effectiveness, to address adherence issues proactively.

Here's the thing:

For nursing homes to achieve better outcomes with CPAP and BiPAP, it’s essential to understand why these devices are prescribed. While they’re commonly associated with sleep apnea, in long-term care, they’re often used to manage chronic hypercapnia and prevent respiratory failure.

These devices can only deliver their benefits if they’re used properly. This requires staff and providers to ask the right questions, educate teams, and prioritize compliance. CPAP and BiPAP are more than just tools—they’re lifelines for the patients who rely on them.

If you’d like to set up education for your facility on CPAP, BiPAP, or other respiratory modalities, reach out to us at [email protected]. Have questions or thoughts? Feel free to share them in the comments or email me directly at [email protected].